Full Name

Date of Birth

Weight / kg

Height / cm

E-mail

Phone

Address

Emergency Contact Name

Emergency Contact Number

Heart Disease

• Yes
• No

Blood in Urine

• Yes
• No

Chest Pain

• Yes
• No

Stroke

• Yes
• No

Heart Murmur

• Yes
• No

Nervous Disorder

• Yes
• No

High Blood Pressure

• Yes
• No

Blood Transfusion

• Yes
• No

Shortness of Breath

• Yes
• No

Hiv

• Yes
• No

Asthma/Emphysema

• Yes
• No

Hepatitis

• Yes
• No

Blood with Coughing

• Yes
• No

Bleeding Tendency

• Yes
• No

Anesthetic Reaction

• Yes
• No

Stomach Ulcers

• Yes
• No

Diabetes

• Yes
• No

Hermia Repairs

• Yes
• No

Thyroid Disease

• Yes
• No

Cancer

• Yes
• No

Arthritis

• Yes
• No

Kidney Stones

• Yes
• No

Anemia

• Yes
• No

Other medical history not mentioned above

Regularly used Medications-Please List

• Yes
• No

Allergic Medications-Please specify

• Yes
• No

Reactions to any medications-Please specify

• Yes
• No

Using any Recreational drugs-Please specify

• Yes
• No

Any Allergies-Please specify

• Yes
• No

Have you ever had General Anesthesia? If its yes, please inform us if you have had any problems after that

• Yes
• No

Smoking

• Yes
• No

Smoking amount a day

Alchol

• Yes
• No

Drink amount a day

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