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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
Allergies
Medication
Blood Thinning Medication
Hormonal Medication
Acid Blocker Medication
E.g.: Nexium, Somac, Zantac, Losec
Other current Medications (including herbal treatments)
Signs and Symptoms

Please select any signs / symptoms you have in each leg

(I.e..: Year, any preceding event (e.g. pregnancy, broken leg), description and progression of symptoms)
E.g.: sitting, standing, exercise.

Have you ever had any of the following?

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

Family Medical History
Please also include their relationship to you
Please also include their relationship to you
Please also include their relationship to you
Please also include their relationship to you
E.g.: Name of (and your relationship to) family member(s) affected by varicose veins.
Investigations
Compression Garments
E.g.: brand, class or strength