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

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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