NAVIGATION

Patient Medical History Form

Please click on the link below to download a copy of the Patient Medical History form. Please complete the form and bring it along to your appointment.

Patient
Medical History Form

Alternatively, forms can be forms can be faxed to (02) 9262 9597, emailed to info@vintagesurgicalspecialists.com
or posted to:

Vintage Surgical Specialists
Unit 3, The
Vintage,
281-287 Sussex St
Sydney NSW 2000

 

Alternatively, fill out the form below:

Patient Information


















Hospital Cover
YesNo

Dental Cover
YesNo



Medical History

Are you under the care of your doctor at present?
YesNo

Are you taking any tablets or medicines at the moment?
YesNo

Have you ever been treated for osteoporosis?
YesNo

Have you ever taken any of the following drugs:
FosamaxActonelSkeliaDidronelArediaZometaBonefos

Are you allergic to any medications or other substances?
YesNo

Have you been in hospital during the last 2 years?
YesNo

Do you smoke?
YesNo

Ladies, are you, or might you be pregnant?
YesNo

If you have, or have had, any of the following conditions please place a tick in the box.
Rheumatic feverEpilepsyAsthmaDiabetesStrokeKidney diseaseHigh blood pressureHeart attack / AnginaHeart murmurHeart pacemakerAnaemiaExcessive bleedingTuberculosisHepatitisHIVThyroid disorderLiver diseaseOther disability

I have further confidential medical information which I do not wish to write down.
YesNo

I have completed this form to the best of my knowledge and it represents my medical history accurately. Any changes will be advised at subsequent appointments.

I agree to be a private patient of this practice and pay the appropriate quoted fee including any collection fees.