Pre-Consultation Medical Questionnaire

Pre-consultation Medical Questionnaire

  • INTRODUCTION

    Prior to your procedure taking place it is necessary to obtain an accurate and detailed medical history. Please complete the following document to the best of your knowledge providing as much detail as possible.
  • 1 . PATIENT INFORMATION

  • 2 . Please answer all of the following questions

  • 3 . Current Health Practitioner Details

  • 3 . Next of Kin Details

  • Patient Health Questionaire

    Please complete the following health questionnaire. Answer ALL questions

  • (check the box if yes, leave unchecked if no)
  • Please insert further comments here if you checked any of the boxes above
  • (check the box if yes, leave unchecked if no)
  • Please insert further comments here if you checked yes for allergies and sensitivities
  • (check the box if yes, leave unchecked if no)
  • Name of Medication Dose Frequency Route