General Information

    First Name: Surname: Email Address:
    Height(cm): Weight(kg): Occupation (If retired, what did you do?):
    Sports/hobbies: Are you Left or Right handed or Ambidextrous?:
    Left HandedRight HandedAmbidextrous

    Past Medical History

    Diabetes:
    YesNo
    Diabetes Type:
    Type IType II
    DVT/PE:
    YesNo
    Epilepsy:
    YesNo
    Asthma:
    YesNo
    Heart Conditions:
    YesNo

    Other:

    Have you had any previous surgery?

    Pacemaker:
    YesNo
    Stents:
    YesNo
    Previous orthopaedic surgery?:
    YesNo
    Any cortisone injections?:
    YesNo

    Other:

    Have you had any problems with a previous anaesthetic?:
    YesNo

    If so, please describe:

    Current Medications

    Pain medications:
    YesNo
    Blood thinners (such as Aspirin/ Warfarin/ Plavix,):
    YesNo
    Glucosamine:
    YesNo

    Other:

    Other Information

    Are you a smoker?:
    YesNoQuit
    If Yes, are you aware that smoking has serious adverse effects on skin and bone healing?:
    YesNo
    If Yes, how many per day & how many years?:

    Do you have any allergies?:
    YesNo

    If so, please list:

    Have you had physiotherapy?:
    YesNo

    If so, where and how many sessions?:
    Do you live alone?:
    YesNo
    If no, who do you live with?:
    SpousePartnerParent/sFriend
    If yes, do you have someone close to you that can help you recuperate?:
    YesNo