Health Questionnaire Form

To provide you with the best possible treatment please complete the following online health questionnaire form. This is a secure SSL encrypted online form.

Alternatively, if you do no wish to complete the form online you can download a PDF of the form to complete manually here: Health Questionnaire (103kb).

Please contact our office on 1300 377 226 if you are unable to complete the form before your visit.


    Your Surgeon


    Patient details

    Do you smoke?*
    NoYes

    Do you drink alcohol?*
    NoYes


    Treatment area

    LeftRightBoth

    ShoulderElbowWristHandHipKneeAnkle/FootNeck/Back/Pelvis


    Medical conditions

    Do you have or have you ever had the following conditions? Please answer all questions.

    Asthma, emphysema, shortness of breath or other lung problems
    NoYes

    Diabetes
    NoYes

    Diabetes controlled by
    DietTabletsInsulin

    Heart attack, palpitations, angina
    NoYes

    Heart murmur
    NoYes

    High blood pressure
    NoYes

    Pacemaker or other heart implants
    NoYes

    Elevated cholesterol/triglycerides
    NoYes

    Stroke (CVA)
    NoYes

    Epilepsy/fits/faints/funny turns
    NoYes

    Stomach problems, gastric ulcer, indigestion or reflux
    NoYes

    Bleeding or clotting disorder
    NoYes

    HIV/AIDS
    NoYes

    Thyroid problems
    NoYes

    Cancer
    NoYes

    Kidney problems
    NoYes

    Hepatitis/liver problems
    NoYes

    Varicose veins
    NoYes

    Deep vein thrombosis (blood clots in the leg)
    NoYes

    Pulmonary embolus (blood clots in the lungs)
    NoYes

    Previous blood transfusions
    NoYes

    Do you take any blood thinning medication such as aspirin, warfarin, Plavix, or anti-inflammatories?
    NoYes

    Depression
    NoYes

    Neck or back injuries/problems
    NoYes

    Problems with anaesthetics, e.g. vomiting
    NoYes

    Do you have any current wound or skin breaks?
    NoYes

    Have you ever had an MRSA (golden staph) infection?
    NoYes

    Have you ever had a VRE infection?
    NoYes


    Medical history

    Which of the following causes you to become short of breath:*
    ExerciseClimbing stairsWalking on the flatAt restUnsure

    Do you know your blood group:
    NoYes

    What is your blood group?*
    ABABO
    PositiveNegative


    Did you complete your own form?*
    NoYes