Patient Registration

Have you had or currently have...

Rheumatic fever
Yes No

ARE YOU A DIABETIC ?
Yes No

DIABETES

Type 1

Type 2

Heart problems

Yes

No

Angina

Arrhythmia

Valve replacement

Stent

Heart murmur
Yes No

Epilepsy
Yes No

Kidney disease
Yes No

Hepatitis
Yes No

Asthma
Yes No

High blood pressure
Yes No

Osteoporosis
Yes No

Stomach reflux/ulcer
Yes No

Excessive bleeding
Yes No

Do you have Allergies to...

Penicillin
Yes No

Aspirin
Yes No

Any other medication?

Any foods?

List

Latex
Yes No

Elastoplast or tapes
Yes No

Any other allergies?
Yes No

List

Have you smoked cigarettes/cigars within the last 4 weeks?
Yes No

Have you EVER taken any medications or had regular injections for osteoporosis or bone conditions/lesions? (eg. Denosumab, Prolia, Fosamax, Actonel, Zometa, Pamisol, Didronel, Didrocal, or Aredia)
Yes No

Please list ALL medications you are currently taking (including vitamin supplements and inhalers)

Please list ALL previous operations

Describe any serious illness you have previously suffered

Females

Are you pregnant?
Yes No

Are you taking the oral contraceptive pill?
Yes No

Have you had problems with general anaesthetics or a family history of malignant hyperthermia?

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