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Confidential Medical History Form

To obtain the best and safest treatment, your surgeon needs to know of the following aspects which may affect your treatment.

Gender
Expectant Mother
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
Are you taking any medications from your doctor? (tablets, creams, injectons, other?)
Are you taking or taken steroids in the last 2 years?
Are you ALLERGIC to any medicines, foods, materials?
Have you had Rheumatic fever?
Have you had jaundice, liver, kidney disease or hepatitis?
Have you ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack?
Have you had any infectious diseases? (including Hepatitis & HIV?)
Have you had a bad reaction to a general or local anaesthetic?
Have you been hospitalized?
Do you have a hip replacement?
Do you have a pacemaker, or have had any form of heart surgery?
Do you suffer from hay fever, eczema or any other allergy?
Do you suffer from bronchitis, asthma or any other chest condition?
Do you have fainting attacks, giddiness, blackouts or epilepsy?
Do you or any member of your family suffer from diabetes?
Do you bruise easily or following a tooth extraction, surgery or injury - have you or your family bled to cause you to be worried?
Do you wear a medical alert bracelet?
Do you ever get cold sores?
Do you smoke anything now? (did in the past?)

Thanks for submitting!

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