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)

If you are unable to complete the form before your visit, please contact our office on 1300 377 226.


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