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Health Questionnaire

Please fill and submit the webform below.

Alternatively – please download, print, fill and bring the completed form with you to your appointment.
Download Health Questionnaire (PDF – 70 Kb)

If you are unable to complete a section of the form, simply ask our administration staff to assist you.

Please note: items marked * indicate mandatory fields.

Please thoroughly fill this Health Questionnaire about vascular concerns. All of your medical history is important in managing your care. Do not exclude any information because you feel it is not important.

Patient Details

Title *

First Name *

Last Name *

Date of Birth *

Day

Month

Year

Sex *

Male

Female

Weight (kg) *

Height (cm) *

Allergies

Allergies

Allergy

Reaction

Medication

Blood Thinning Medication

Do you currently take aspirin or any other medication to thin the blood? *

Yes

No

Blood Thinner Medication Name *

Blood Thinner Medication Dose *

Hormonal Medication

Do you currently take any hormonal medication? *

Yes

No

Hormonal Medication Type *

Hormone replacement therapy (HRT)

Oral Contraceptive Pill (OCP)

Other

Hormonal Medication Name *

Hormonal Medication Dose *

Acid Blocker Medication

Do you currently take any acid blockers for indigestion/reflux/stomach ulcers? *

Yes

No

E.g.: Nexium, Somac, Zantac, Losec

Acid Blocker Medication Name *

Acid Blocker Medication Dose *

Other current Medications (including herbal treatments)

Medication Name

Medication Dose

Medication Frequency

Have you ever had any of the following?

Deep Vein Thrombosis (blood clot in deep vein) *

Yes

No

Pulmonary Embolism (blood clot in the lungs) *

Yes

No

Superficial Thrombophlebitis (blood clot in superficial vein) *

Yes

No

Blood condition that makes your blood thicker or more likely to clot? *

Yes

No

Stroke or Transient Ischaemic Attack (TIA) *

Yes

No

Vitamin B12 deficiency *

Yes

No

Iron deficiency *

Yes

No

Multiple miscarriages *

Yes

No

Please specify number of miscarriages *

History of Malignancy (cancer) *

Yes

No

Please specify details of cancer *

Inflammatory Conditions *

Yes

No

E.g.: psoriasis, arthritis, irritable bowel syndrome, sinusitis, asthma, ankylosing spondylitis, diverticulitis, reflux, fibromyalgia, Parkinson's, hepatitis, lupus.

Inflammatory conditions details

E.g.: psoriasis, arthritis, irritable bowel syndrome, sinusitis, asthma, ankylosing spondylitis, diverticulitis, reflux, fibromyalgia, parkinson's, hepatitis, lupus, etc.

Please select any of the following that apply

Smoker Status *

Never smoked

Ex Smoker

Current Smoker

How many years did you smoke?

When did you quit?

How many cigarettes per Day?

High Blood Pressure *

Yes

No

Is your blood pressure well controlled? *

High Cholesterol *

Yes

No

What is your usual cholesterol reading? *

Diabetes *

Yes

No

Type of Diabetes *

When was your diabetes diagnosed? *

Asthma *

Yes

No

Have you ever been admitted to hospital for asthma? *

Yes

No

When was your asthma diagnosed? *

Epilepsy *

Yes

No

Frequency of epileptic seizures *

Migraines / Headaches *

Yes

No

Other than general pain what are your associated migraine / headache symptoms? *

Anxiety *

Yes

No

Depression *

Yes

No

Any psychiatric conditions *

Yes

No

Psychiatric condition details

Peripheral Neuropathy (altered sensation in feet) *

Yes

No

Thyroid problems *

Yes

No

Heart Attack *

Yes

No

When did you experience heart attack? *

Chest pain or angina *

Yes

No

How often do you experience chest pain or angina? *

Arrhythmia / Abnormal heart rhythms *

Yes

No

What kind of Arrhythmia / Abnormal heart rhythms? *

Heart Murmur *

Yes

No

Hole-in-the-heart / septal defect also known as a patent foramen ovale (PFO)? *

Yes

No

When were you diagnosed and what tests were performed. *

Any other heart condition? *

Yes

No

Other heart condition details

Do you have claudication? (Leg cramps when walking) *

Yes

No

Do you have arterial disease (blockage or narrowing in an artery)? *

Yes

No

Arterial disease details

Do you normally take antibiotics before medical or dental procedures? *

Yes

No

Reason for antibiotics before medical or dental procedures *

Kidney conditions *

Yes

No

Liver conditions *

Yes

No

Stomach ulcers *

Yes

No

Bowel Polyps *

Yes

No

Conditions affecting the blood *

Yes

No

Have you ever had a blood transfusion? *

Yes

No

Why did you have a blood transfusion? *

Do you have HIV/AIDS or been exposed through IV drug use, tattoos or sexual partners? *

Yes

No

Do you have any other illnesses not already mentioned? *

Yes

No

Other illness details *

Have you ever been admitted to hospital? *

Yes

No

Details of when you were admitted and for what condition

Family Medical History

Investigations

Have you had any tests or investigations in the last 12 months? *

Yes

No

Name of test and Doctor who requested the test *

Are you currently under the care of any other specialists? *

Yes

No

Specialist Details *

Compression Garments

Do you wear compression garments? *

Yes

No

Where did you buy your compression garments? *

When did you buy your compression garments? *

What kind of compression garments? *

E.g.: brand, class or strength

Are they comfortable? *

Yes

No

Have you ever had custom made compression before? *

Yes

No

Where were your custom compression garments made? *