Medical History Questionnaire - Cardiac Surgery

Please complete this form carefully and honestly supplying as much of the information as you can. Your GP may be able to assist with this. Omitting relevant information may cause difficulties for you or the treating facility and may make it not possible for your treatment to proceed.

Fill the required Field

Questions	Yes / No	Answer
Which Surgery is planned? *
Are you allergic to any medication? If the answer is yes, please list them *	Yes No
Are you allergic to sticking plaster? *	Yes No
Are you allergic to any other products? If the answer is yes, please list them. *	Yes No
Do you smoke? If so, how many a day? *	Yes No
How many units of alcohol do you consume weekly? *	Yes No
Are you able to carry out normal physical activities? What are you unable to do? *	Yes No
Do you wear spectacles? *	Yes No
Do you wear contact lenses? *	Yes No
Do you wear dentures? *	Yes No
When did you last visit the dentist? *
Have you ever been treated for eye disease? If so, which? *	Yes No
Do you snore at night? *	Yes No
Have you had any previous surgery? If so for what operation and when? *	Yes No
Have you ever suffered from any problems with anaesthesia such as: Vomiting? *	Yes No
Or Pain? *	Yes No
Or Confusion? *	Yes No
Or Respiratory difficulties? *	Yes No
Or Other issues? *	Yes No
Have you ever had a blood transfusion? If so when *	Yes No
What is your blood group? *
Do you suffer from any other medical problems? *	Yes No
Do you feel nauseous or unwell at the moment? *	Yes No
Do you take medicines? If yes, which and how much? Please supply complete list on separate sheet if necessary. *	Yes No
Do you bleed for long after a tooth extraction or injury? *	Yes No
Do you have any history of heart condition, constriction, pain in the chest, palpitations of the heart or heart attack? *	Yes No
Have you ever suffered from bronchitis, pneumonia, asthma or shortness of breath? *	Yes No
Are you diabetic? *	Yes No
Do you suffer from: kidney disease? *	Yes No
Liver disease? *	Yes No
Thyroid disease? *	Yes No
Nerve disorders? *	Yes No
Do you suffer from high blood pressure? *	Yes No
Any other disease not mentioned here? *	Yes No
Do you wish to mention anything special? *	Yes No
Have you recently had a cold or flu? If so, when? *	Yes No

Medical History Questionnaire - Cardiac Surgery

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GP’s Details

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Medical History Questionnaire - Cardiac Surgery

Next of Kin Details

GP’s Details

Please answer the following questions: