Mr Matt Walker Orthopaedic Surgeon for Hip and Knee joint

GENERAL DETAILS

Patient Name: (i.e. Legal name used on health documents) *

First

Last

Preferred Name: (if different from above)

Date of Birth: *

Gender: *

Email: *

Confirm Email

Mobile Number:

Home Number:

Work Phone:

Best way to contact you: *

Email
Mobile
Work

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Emergency Contact Person's details: *

First

Last

Your GP and name of the GP practice: *

First

Last

Your occupation: *

Do you have medical insurance? *

Which Insurance Company? *

What is your membership number?

HEALTH QUESTIONS

Check any condition you suffer from, or have ever suffered from:

Chest pains / Tightness or angina
Previous Rheumatic Fever
Palpitations
Heart Murmur
High Blood Pressure
Artificial Heart Valve or Pacemaker
Hiatus Hernia / Indigestion
Diabetes – Oral Medication
Kidney Disease
Rheumatoid Arthritis
Shortness of Breath
Asthma
Emphyema or Bronchitis
Tuberculosis
Obstructive Sleep Apnoea
Persistant Cough
Stroke or Seizures
Jaundice or Hepatitis
Thyroid Disease
Previous DVT or Lung Clot
Bleeding or Clotting Disorder
Motion Sickness

Please tell us more about any condition you ticked above:

What's your weight? *

What's your height? *

Do you smoke or vape? *

How many per day? *

Do you drink alcohol? *

How many units per week? *

Have you had Covid? *

Date of positive test: *

Are there any major illnesses, to your knowledge, in other blood relatives?

How many flights of stairs can you climb before getting out of breath? *

One flight or less
Two flights
Three flights or more

Your activity mostly is limited by: *

Shortness of breath
Chest pain
Joint pain
Other
No limitation

PREVIOUS SURGERY

Have you had any previous surgery? *

Please list ALL previous surgery including year and hospital if known:

Have you had any difficulties during Anaesthesia that you know of? *

Yes
No
No past surgey

Anaesthetic issues:

Do you have dentures, a partial plate, capped or loose teeth? *

MEDICATIONS

Do you take medications and/or drugs (including herbal)? *

Medication # 1:

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Middle

Last

Medication # 2:

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Middle

Last

Medication # 3:

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Middle

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Medication # 4:

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Middle

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Medication # 5:

First

Middle

Last

More Medications to add? *

Medication # 6:

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Middle

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Medication # 7:

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Middle

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Medication # 8:

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Medication # 9:

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Medication # 10:

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Middle

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Do you have ALLERGIES to medicines, plasters, food, or latex etc? *

year Mailing Address:

List substance causing allergy and the effect:

Are you or could you be pregnant?

List any conditions, not covered elsewhere, that you feel we should know about:

Additional Questions or Comments:

Privacy Statement: Your privacy is important to us. We are committed to ensuring your privacy is respected and maintained at all times. The information we collect is required to help provide safe care and treatment. We are required to provide Government agencies (e.g. ACC) and other organisations (e.g. insurance companies) with information only to which they are legally entitled. If there is any doubt as to whether a third party is entitled to information about you, we will contact you directly to seek permission to release the information. You have the right to request your notes and we are happy to provide them to you at any time. In the event of you requiring surgery, this form will be provided to the team members responsible for your care e.g. the Anaesthetist.

You acknowledge the statement above and consent to this form being processed:

Date: *

GENERAL DETAILS

HEALTH QUESTIONS

PREVIOUS SURGERY

MEDICATIONS

Our Address

Contact Us

Office Hours