MEDICAL HISTORY
| Patient name: |
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| Medication (include pain relief, aspirin, the pill, HRT, vitamins): |
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| Allergies: |
| Number of cigarettes per day: |
| Alcohol: |
| Exercise: |
| Asthma: |
| Bleeding: |
| Anaemia: |
| Thyroid: |
| Heart: |
| Hypertension (last day checked): |
| Epilepsy/fitting: |
| Diabetes: |
| Keloid tendencies: |
| Skin disorders (sensitivity to tape): |
| Herpes/cold sores: |
| Hepatitis (exposure; tested; immunised): |
| HIV: |
| Past surgery & dates: |
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| Problems with general anaesthetic: |
| Problems with local anaesthetic: |
| Currently pregnant or breastfeeding: |
| Other medical history: |
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| HAVE YOU VERIFIED YOUR GP'S NAME AND ADDRESS? |
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| Signature: |
date: |
20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile:
(02) 9328 6036
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