Health QuestionnairePlease complete this short series of questions regarding your current health situation. Name * First Name Last Name Are you diabetic? * Yes No If yes, what type? Diet Tablets Insulin Are you a smoker? * No Yes If yes, how many cigarettes a day do you smoke? Do you take any of the following medications? * Please select all that apply. Warfarin Aspirin Iscover Pradaxa Plavix Methotrexate Endone Oxycodone Pain Patches Prednisolone Anti-Inflammatories None Please list all other tablets that you take * Please list any allergies that you have Do you have any of the following? * Severe Anaesthetic Reactions Cardiac Stents Pacemaker History of Blood Clots (DVT/PE) Blood Vessel Disease Depression None Do you have someone to care for you while you recover from surgery? * Yes No Can you arrange time off work and alternative work duties if required? * Yes No Thank you!
