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Apollo Plastic Surgery

Plastic, Reconstructive, Cosmetic and Hand Surgery in Hamilton, New Zealand

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office@apolloplasticsurgery.com

Tel: 07 838 8984

Enter full details here prior to booking for surgery

Title

First Name

Last Name

Preferred name

Date of birth

Gender

NHI Number (if known)

Phone (home)

Phone (mobile)

Email

Address

GP Name

GP address

Occupation

Ethnicity

Next of kin - Name

Next of kin - Relationship

Next of kin - Contact details

List allergies e.g. drugs / food

Prior or current medical problems - select all that apply

Anaemia

Antibiotic resistant infection e.g. MRSA

Arthritis

Asthma

Blackouts / severe headaches

Bleeding problems e.g. Von Willebrand

Blood clots in legs or lungs

Diabetes

Epilepsy or convulsions or fits

Hearing difficulties

Heart attack

Blood borne disease e.g. hepatitis / HIV

Do you stop breathing when sleeping?

High blood pressure

Kidney problems

Muscle or nerve problems

Rheumatic fever / heart disease

Shortness of breath

Sight impairment

Stroke / Transient ischaemic attack (TIA)

Swollen ankles

Tuberculosis

Unusual thumping or beating of your heart

Problems with previous anaesthetics

Do you smoke?

Have you smoked in the past?

Other illnesses - please specify

Do you drink alcohol or take recreational drugs

Height (cm)

Weight (kg)

Current medication

Recent history

Have you been admitted to hospital / facility in the last 6 months?

Have you been in contact with an infectious person in the past 7 days

Are you vaccinated against COVID 19?

Have you had any infectious symptoms in the last 7 days?

Do any of your blood relatives have, or have they had:

Bleeding or clotting problems

An inherited muscular weakness

Unusual reaction to anaesthetic

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Health Questionnaire: Contact Me

Apollo Plastic Surgery

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