Personal inquire of the medical questionnaire

Before coming to be operated, people need to fill out this questionnaire
in order to prepare correctly the operation.

[*Required fields]

Personal inquire of the medical questionnaire

Full Name* Address* Phone/Mobile* Email* Current Passport* NHS Trust* NHS Address* NHS Phone*

Medical History of the medical questionnaire for hip replacement

Your Weight (Kg)*

Is it the first time you’ll be operated on this joint?* Yes No

If Yes, explain the last operation:

Have you had any operation of heavy treatment?* Yes No

If Yes, explain this:

Do you have taken Aspirin or an Anticoagulant?* Yes No

If yes, type and amount:

Do you have problems with?

Anaesthetic or respiration Allergies Drugs High Blood Pressure Diabetes Asthma Heart Disease or Angina Varicose Veins or Phlebitis

Have you ever had?

A Blood Transfusion
or Coagulation problems Stroke, Convulsion or Epilepsy Stomach, Liver or Thyroid problems Parkinson’s Disease Sciatica

You need to have a visit to your Dentist surgeon to extract the potential infected teeth before the operation. You must send this medical report, even if there is any damaged teeth.