Admission FormPlease fill this form to the best of your knowledge. Name * First Name Last Name Date of Birth * MM DD YYYY Sex * Male Female Home Phone (###) ### #### Mobile Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Next of Kin Name * First Name Last Name Contact * (###) ### #### Patient History Please fill carefully 1. Have you had any serious illness? * Yes No Unsure 2. Have you had anaesthesia before? * Yes No Unsure 3. Have you had any problems with anaesthesia? * Yes No Unsure 4. Do you have cold or nasal problems? Yes No 5. Do you get breathless on exercise or on lying down? Yes No 6. Do you get swollen ankles? * Yes No 7. Have you had heart disease, rheumatic fever or high blood pressure? * Yes No Unsure 8. Do you have Bronchitis, asthma or any chest problems? * Yes No Unsure 9. Have you had convulsions or fits? * Yes No 10. Have you had arthritis or prolonged muscle disease? * Yes No 11. Have you had anaemia or any blood disorders? * Yes No 12. Do you bruise easily or bleed excessively? * Yes No 13. Have you ever had jaundice? * Yes No 14. Have you ever had urinary or kidney problems? * Yes No 15. Have you ever had diabetes or sugar in the urine? * Yes No 16. Are you allergic to any medication? Yes No 17. Are you allergic to anything else? * Yes No 18. Do you smoke or drink a lot of alcohol? Yes No 19. Do you have dentures or contact lenses? * Yes No Addtional Information If you wish to share any other information you think we should know, please type below. Special Requests Dietary Other Thank you!
