Recent cold Bronchitis Asthma Hayfever Emphysema Shortness of breath Any other lung problems Elevated cholesterol / triglycerides High blood pressure Chest pain, angina Heart attack(s) Palpitations Do you have a pacemaker? Heart murmur Artificial implants/devices Gastric ulcer / reflux Stroke Varicose veins Rheumatic fever Polio, meningitis Limb paralysis Anaemia Jaundice, hepatitis Low blood sugar Arthritis Fits / faints / funny turns / epilepsy Diabetes controlled by a) injection b) tablet c) diet Thyroid trouble Kidney trouble / dialysis Gout Depression / mental illness Cancer Glaucoma SYDNEYADVENTISTHOSPITAL Reason for your admission:................................................................................................................................................... ............................................................................................................................................................................................... ............................................................................................................................................................................................... Language spoken: English Other................................................ Is an interpreter required? Yes No Do you consent to the hospital communicating with your General Practitioner if required? Yes No If yes, please specify: GP's full name:.................................................................................Phone:................................................................... Address: ...........................................................................................Fax: ....................................................................... PATIENTHISTORYMR26A GP - 1225 PATIENT HISTORY To be completed by the patient or carer Y N Y N Y N PREVIOUS HOSPITALISATION / SURGERY / ILLNESS: Please tick the Yes or No box regarding your medical history Please list any previous surgery or illnesses including dates if possible, or any other type of condition that may require further explanation................................................................................................................................................ .......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... What is your: height____________cm weight____________kg Previous blood transfusion Blood clots Back injuries / problems Neck injuries / problems Infections Do you have any wounds / skin breaks? Are you pregnant? / weeks Have you had any problems with anaesthetics, eg vomiting Have you ever smoked? / day Do you presently smoke? / day Do you drink alcohol? / day Past history of drug dependency Do you have Creutzfeldt-Jacob Disease (CJD)? Have you had: a) Human Pituitary Growth Hormone prior to 1985? b) neurosurgery prior to 1985? Page 1 of 2 I have carefully read all the above and I certify that the information I have given is correct and true to the best of my ability. Signature:...........................................................................................Date: ...................................................................... Surname Given names DOB Home phone no Address Sydney contact phone no Admission date Admitting doctor Admitting doctor phone no DIETARY REQUIREMENTS Do you require a special diet? Yes No Please specify:..................................................................................... ............................................................................................................................................................................................. ............................................................................................................................................................................................. ALLERGIES AND SENSITIVITIES Please document any known allergies or sensitivities. eg: medications, latex, food, plants, tape Allergy Sensitivity Reaction Example Only Surname Given names DOB SYDNEYADVENTISTHOSPITAL PATIENTHISTORYMR26A PATIENT HISTORY YOUR CURRENT MEDICATION LIST Please include all tablets, capsules, puffers, nebulisers, patches, insulin, eye drops. Please consult your GP or surgeon if you are unsure of any details about your prescribed medications or which medications should be ceased prior to your surgery. Bring to the hospital all current medications you are taking, in their original packaging. Prescription drugs Medication Strength Route Dose Frequency Geranin 100mgs Oral 2 tablets 3 times a day Asmin 0.4mgs Inhale 2 puffs 4 times a day DISCHARGE ARRANGEMENTS For Day Patients only: Have you organised who will take you home? Yes No If yes, Name______________________Relationship ________________Best contact Phone no_________________ For inpatients: please note that discharge time is 10am or Mobile no_________________ If you are taking any non-prescription medication eg. complementary therapies, natural therapies, herbal preparations or vitamins, please specify. Non-prescription medication Name Strength Route Dose Frequency Page 2 of 2 I have carefully read all the above and I certify that the information I have given is correct and true to the best of my ability. Signature:.............................................................................................Date: ......................................................................