MEDICAL HISTORY QUESTIONNAIRE

MEDICAL HISTORY QUESTIONNAIRE


PERSONAL INFORMATION
Firstname/s: Surname: Sex:
Age: Height: Weight: kg
ID No: Contact No: Email Address:
Address:



NEXT OF KIN
Firstname/s: Surname: Contact No:

Please complete the questionnaire below indicating if you suffer from, or have a history of, any of the following, by clicking yes. There is a space at the end of each section for an explanation should you have clicked yes.

All information is treated as strictly confidential and only your sedationist will be furnished with your medical details.



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If yes, what was your last blood pressure reading?
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If yes, please provide details below of medication and degree of control
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IS THERE ANYTHING ELSE YOU WOULD LIKE TO ADD?

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