• BroadmeadowForster, Maitland or Port Macquarie
  • Your answers will help our surgeons provide you with the most appropriate treatment
  • The information you give is strictly confidential
  • Your honesty may assist in avoiding health problems
  • NoYesHeart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details

  • NoYes
  • NoYes

    If yes, please tick where appropriate
    WarfarinAspirinPlavixAny other blood thinning medication

  • NoYes

    If yes, please tick where appropriate

    PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details

    Reactions: RashSwellingVomitingOther, give details

  • NoYes

  • NoYes

  • NoYes

  • NoYes
  • NoYes
  • NoYes
  • NoYes

    < 1020-3030-60More
  • NoYes

    0-55-1010 or more
  • NoYes

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  • HospitalDental
  • Dentist (as above)GP (above)Other (please enter details below)
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