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Patient Information:
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Patient Full Name: *
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Patient Address: *
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Patient Contact Number: *
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Patient Email Address: *
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Patient Age: *
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Patient Height: *
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Patient Weight: *
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Main Complaint:
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Investigation
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Book an Appointment:
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Please choose your preferred date and time of appointment below. After Hour appointments are subject to availability:
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Preferred Surgeon: *
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Preferred Appointment Date: *
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Preferred Appointment Time: *
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Patient Medical History:
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Do you have or have you ever had the following conditions?
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High Blood Pressure: *
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Elevated Cholesterol/triglycerides: *
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Pacemaker: *
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Diabetes: *
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If yes to diabetes, controlled by:
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Hepatitis: *
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Varicose Veins: *
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Deep Vein Thrombosis: *
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Depression: *
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Asthma: *
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Emphysema, shortness of breath or other lung problems: *
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Sleep Apnoea (CPAP): *
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Stroke (CVA): *
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Epilepsy, fits, faints or funny turns: *
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Cancer: *
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Kidney Problems: *
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Stomach problems, gastric ulcer, indigestion or reflux *
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Do you take aspirin, blood thinning medication or anti-inflammatories? *
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Neck or Back Injuries/Problems *
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Do you have any wound or skin breaks? MRSA? *
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Do you smoke or have you ever smoked? *
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If you do smoke, how many packs per day?
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Do you drink alcohol? *
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If you drink alcohol, how much per day?
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Problems with anaesthetics, e.g. vomiting *
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Other medical conditions:
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Other specialists involved in your care?
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Previous surgery, including dates if possible:
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Current medications, including herbal preparations:
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Allergies to medications, metals and other:
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We will contact you within 24 hours to confirm your appointment.
If a matter is urgent please contact the office.
If the matter is an emergency, please ring 000.
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Security Code *
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