Medical History Form

Patient Details
Emergency Contact
X-Rays
Have you had an X-Ray done at MIA, Capital Radiology or Clayray
Yes
No
Payment Details

  • Payment for consultation is required at the time of consultation.
  • Pre-payment is required prior to any surgical procedures.

  • Cash, credit cards including AMEX, electronic fund transfer.
  • We do not accept personal cheques.


  • Do you belong to a health Fund:

    Others:
    DVA
    Work Cover
    TAC
    Other
    Please provide Medicare number:
    Medicare reference number besides name:
    Do you currently, or have you ever suffered from any of the following conditions?

    Please tick:

    Asthma
    Diabetes
    Epilepsy or fits
    Angina
    Stroke or Heart Attack
    Heart Trouble
    Kidney Disease
    Excessive Bleeding
    Hi or Lo Blood Pressure
    Anaemia
    Sleep Apnoea
    Reflux
    Other
    Serious issues with previous anaesthetics
    Do you have any allergies? (e.g. penicillin, codeine)
    Do you take any drugs, tablets, medicines or cream?
    Have you ever taken Fosamax or any drugs for your bones?
    Ladies, are you pregnant or could you be?
    Do you smoke?
    Have you had any significant medical problems in the last year?
    Continue