RL-long-rgb

Fill out the Health Questionnaire below or Download the PDF (right) and bring it with you to your first appointment.
Download Questionnaire

Health Questionnaire

    General Information

    First Name: Surname: Email Address:
    Height(cm): Weight(kg): Occupation (If retired, what did you do?):
    Sports/hobbies: Are you Left or Right handed or Ambidextrous?:
    Left HandedRight HandedAmbidextrous

    Past Medical History

    Diabetes:
    YesNo    		 Diabetes Type:
    Type IType II    		 DVT/PE:
    YesNo    		 Epilepsy:
    YesNo    		 Asthma:
    YesNo    		 Heart Conditions:
    YesNo

    Other:

    Have you had any previous surgery?

    Pacemaker:
    YesNo    		 Stents:
    YesNo    		 Previous orthopaedic surgery?:
    YesNo    		 Any cortisone injections?:
    YesNo

    Other:

    Have you had any problems with a previous anaesthetic?:
    YesNo

    If so, please describe:

    Current Medications

    Pain medications:
    YesNo    		 Blood thinners (such as Aspirin/ Warfarin/ Plavix,):
    YesNo    		 Glucosamine:
    YesNo

    Other:

    Other Information

    Are you a smoker?:
    YesNoQuit    		 If Yes, are you aware that smoking has serious adverse effects on skin and bone healing?:
    YesNo
    If Yes, how many per day & how many years?:

    Do you have any allergies?:
    YesNo

    If so, please list:

    Have you had physiotherapy?:
    YesNo

    If so, where and how many sessions?:
    Do you live alone?:
    YesNo    		 If no, who do you live with?:
    SpousePartnerParent/sFriend    		 If yes, do you have someone close to you that can help you recuperate?:
    YesNo