Patient Information
Emergency Contact Info
Social History
Aboriginal/Torres Strait Islander* YesNo
What is your country of birth? *
How many children do you have?
Occupation *
Do you live alone? * YesNo
Smoking History * ActiveEx-SmokerNo
Number a day
Years of Smoking
Year Quit
Alcohol Intake * YesNo
How many days per week?
How many standard drinks per day?
Any recreational or street drugs used before * YesNo
Medical History

Have you ever had any of the following? Please tick those that apply:
AnaemiaArtificial JointsAsthmaBlood DiseaseHigh Blood PressureCancerDizzinessEpilepsyExcessive BleedingDiabetesFaintingGlaucomaHeart DiseaseHeart MurmurHepatitis A, B, CJaundiceKidney DiseaseLiver DiseaseHIVPacemakerRadiation TherapyRepiratory ProblemsRheumatic FeverSinus ProblemsStrokeTuberculosisTumorsPsychological DisordersOther