Medical History Questionnaire – Melbourne Respiratory & Sleep Services

226 Burgundy Street
Heidelberg VIC 3084
Ph: 9459 0555
Fax: 9455 0786

Personal Details

Name

Date of Birth

Allergies

Are you allergic to any medications, foods, tapes, lotions, latex?

Comments

Past Health (Comment if yes)
Do you have or have you ever had?

Heart trouble eg. Heart attack, chest pain, angina, palpitations, irregular heartbeat or heart surgery?

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Insertion of pacemaker, heart valve or stent?

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Personal or family history of cancer?

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Blood pressure problems?

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Stroke, "mini-strokes", blackouts, migraines, brain surgery?

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Blood clot in lung or leg?

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Anaemia, bleeding tendency or blood disorder? Eg: leukaemia

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Breathing problems or lung disease? eg asthma, bronchitis, emphysema, sinus, hayfever, T.B or pneumonia

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Fitting or convulsions/epilepsy or fainting?

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Diabetes/ Thyroid problems?

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Kidney or bladder problems? Eg: incontinence or infections

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Bowel problems? Eg: constipation, haemorrhoids, bleeding inflammatory bowel disease

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Gastric reflux, indigestion, stomach ulcer or hiatus hernia?

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Liver disease? Eg: hepatitis, jaundice, Pancreatitis?

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Infectious diseases? Eg HIV, hepatitis – what type, TB

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Arthritis, back or neck problems, spinal surgery, fractures?

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Mobility problems?

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Psychiatric, psychological problems?

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Any other health problems not listed above?

Comments

Do you smoke?

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Do you drink alcohol?

Comments

Medications

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Dose

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