Concord Pre-Procedure Health Questionnaire Form

Hospital Contact Reference Number/Medical Record Number

Patient's Surname

Patient's Given Name

Patient's Phone Number

Patient's Date of Birth

Patient's Sex

Male Female Indeterminate

Patient's Weight

Patient's Height

Form Completed By

I'm not a robot

Surgery Date (if known)

Surgeon (if known)

Name of Operation/procedure (if known)

What health problems are you coming into hospital for?

What Cardiac, Respiratory or other health problems do you have now?

What operations and/or major illlnesses have you had in the past?

Have you been in hospital in the last six months?

Yes No

Please give details

Do you see a Cardiologist?

Yes No

Please give details

Do you have any allergies (medicines, sticking plaster, iodine, latex or food)?

Yes No

Allergy Details

Allergy Details:

Have you had any blood tests done in the last 4-6 months?
If so name of Pathology company:

Upload any blood tests, consult letters to the PPHQ - as PDF
(no special characters allowed in filename!):

Pre-Procedure Health Questionnaire Form

Pre-Procedure Health Questionnaire
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