Medical Background Check

First Name (required)

Last Name (required)

Date of Birth (required)

Your Email (required)

Home Address (required)

Do you take Allergies medication? (required)
YesNo

Have you had any infectious diseases or porter of a viral infection?
( HBsAg, HIV, HCV, etc) (required)
YesNo

Do you take Anaemia medication? (required)
YesNo

Do you take Asthma medication? (required)
YesNo

Do you take Birth control - The pill? (required)
YesNo

Please indicate your Blood pressure level (required)
HighNormalLow

Do you have Deep Vein Thrombosis/ Blood Clots? (required)
YesNo

Do you use Depression medication? (required)
YesNo

Do you have Diabetes? (required)
YesNo

Please describe Current and prescribed Medication you are taking

Past Medical History that needs mention

Do you drink or smoke?

How many cigarettes do you smoke per day?

Have you or your family ever had difficulties with General Anaesthetic?
YesNo

Do you have any known heart problems?
YesNo

Have you ever been jaundiced?
YesNo

Are you able to carry out physical activities?
YesNo

Have you had any previous surgery ? If so for what operation and when ?
YesNo

Do you wish to mention anything special?