Personal Details

Medical History
Have you had any operations? Include tonsils, appendix, male or female sterilisation and the year of the operations.

Have you been in hospital for any other illness? Or been treated at home for any serious illness? Include the year of any illnesses.

Have you ever seen a specialist about any other problem? Include the year of the specialist appointments.

Do you have any long-term illness or disability? E.g. raised blood pressure, skin complaint, diabetes, asthma, mental health conditions. Inlcude the year disability started.

Medical History
Please list any current medications.

Are you on any blood thinning medication? E.g. aspirin, dabigatran, rivaroxaban, warfarin.

Are you allergic to any drugs?

I understand that any information provided by me will remain confidential in line
with the terms of the Health information Privacy Act.
Yes
I understand Raumati Road Surgery is seeing me as a casual patient.
Yes
I understand payment is required on the day of consultation.
Yes

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