FULL NAME		
ADDRESS		
DATE OF BIRTH 		
TELEPHONE NUMBER		
E MAIL		

GP DETAILS	

Pre-Admission Medical Questionnaire

The medical information you supply will be kept confidentially the appointed hospital, and will only be disclosed to others on a strictly confidential basis in connection with and for the purpose or treatment and or admission relating to the proposal treatment.

I Agree to the release of copy medical records and information in relation to this treatment.

Signed : 								Date :

PAST MEDICAL HISTORY

Please tick any of the diseases, if you have ever suffered from them in the past.
Give the year at time of onset in the second column

HAVE YOU EVER SUFFERED FROM

	Tick	Year      	
Heart attack			
Angina			
Irregular heartbeat			
Other  heart diseases			
Stroke			
High blood pressure			
Do you have a cardiac pacemaker?			
Do you have ankles swell?			

	Tick	Year	
Bronchitis			
Asthma			
Tuberculosis			
Pneumonia			
Pleurisy			
Emphysema			
Shortness of breath at exertion			
Shortness of breath at rest			
Persistent cough			
Coughing up blood			
	Tick	Year	
Diabetes			
Thyroid disorder			
Other glandular disorder			
			
Kidney disease			
Kidney stone			
Prostate disease			
Urinary infection including cystitis			
Urinary problems			
Frequency day time ?			
Frequency night time ?			

	Tick	Year	
Cancer			
(please give details)			

	Tick	Year	
Peptic ulcer			
Hernia/ rupture			
Gall stone			
Piles or anal fissure			
Polyps in the colon			
Colitis including diverticulitis			
Hiatus hernia			
Appendicitis			
Indigestion			
Hepatitis			

	Tick	Year	
Conjunctivitis			
Glaucoma			
Ear disease or discharge			
Ringing in the ears			
Vertigo			
Hearing problems			
Do you wear a hearing aid?			
Do you wear glasses?			
Do you wear contact lenses?			
Do you have dentures?			
Do you have capped or crowned teeth			

	Tick	Year	
Varicose veins			
Leg ulcers			
Pains in the legs when walking			
Thrombosis in leg			
Phlebitis			

	Tick	Year	
Tropical diseases (malaria, dysentery...)
Please give details

			

	Tick	Year	
Back problem 
Please give details

Arthritis			
Lumbago			
Sciatica			
Rheumatism			

	Tick	Year	
Nervous emotional disorder			
Depression			
Anxiety			
Fits or seizures including epilepsy			
Migraine/ Headaches			
Fainting or dizzy spells			

	Tick	Year	
Skin disease
Please give details

			
Muscle or nerve disease
Please give details

			

Have you ever suffered from a serious accident or injury, please give details :

	

Have you previously had an operation?  YES / NO 	
Year and what kind of operation :
	
Year and what kind of operation :
	
Year and what kind of operation :
	
Year and what kind of operation :
	
Have you previously had an anaesthetic? 

Did you have any complications or reactions? Please give details

	

Are you taking any drugs, medicines or tablets( including aspirin and inhalers) 
(If YES, please make a list)

	

	

Have you ever been treated with steroid drugs? (hydrocortisone or prednisolone?)

If YES, when did you stop taking them : 

Have you ever been treated with anticoagulants : 

If YES, when did you stop taking them : 

	

Have you ever had a bad reaction to drugs? 

If YES , which drugs  :

	
	
Allergies ( Hay fever, Elastoplast, food, metal, animals ........)

	
Please confirm which joint is to be replaced, e.g Left Hip