SLHD Concord Logo     Pre-Procedure Health Questionnaire Form

Pre-Procedure Health Questionnaire Form

Please answer every question as best you can.
If necessary, ask a relative, friend or your general practitioner to help you.
 

Patient Information

Male       Female       Indeterminate

Health Details

Yes       No
Yes       No
Yes       No

Medications/Lifestyle

Yes       No
Please list ALL drugs or medications, herbal or other therapies that you have taken in the last month:
    Name   How much (dose)?   How often?  
>> Add
Yes       No
Yes       No      
Yes       No      
Yes       No      
Yes       No
Yes       No
Yes       No
Yes       No
Four Flights (2 Floors)
Two Flights (1 Floor)
One Flight (8 Steps)
Around the house only
Yes       No
Yes       No

Pre-Existing Medical Conditions

Do you or Have you had?
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No

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Page Last Updated: 24 February, 2020