| Procedure you wish to undergo? |
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| If the answer is Yes to any of the above, please send us the details: |
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| Any other past medical history that needs mention: |
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| Current and prescribed Medication you are taking if any: |
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| Do you drink or smoke? |
Ciggererattes/ day
drinks/ day |
Please note: Smoking can cause delayed recovery, wound breakdown and increased
risk of infection. We strongly recommend
that you stop smoking 2 weeks before and
2 weeks after surgery. |
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Have you been referred for consultation
with a psychiatrist or psychologist? |
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If so, what treatment have you been on?
For how long? |
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Have you suffered from previous deep vein thrombosis, i.e. blood clots, developing in
the leg following long air flights, long
hospital stays, etc? |
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If so, when was this, what treatment
were you prescribed for how long? |
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| Do you have any allergies with drugs? |
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Did you have any reactions to local or
general anesthetic in the past? |
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| Are you prone to KELIODS or poor scaring? |
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How would you describe your general
health - including diet and fitness? |
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| What is your pain threshold like? |
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| If any medical report upload here |
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| Do you have any questions or concerns? |
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