Patient Details

Title

Mr.Mrs.Ms.MissDr.Other

First Name

Last Name

Date of Birth

Phone Number

Address

Street addressStreet address line 2

City

State

Postcode

Country

Private Health Insurance Membership No

Private Health Insurance Provider or type 'Nil' *

Medicare Card Number

Assistance/Special Needs/Mobility Concerns

Medicare & Healthcare Information

Appointment Type

Select which applies to you *

Medicare CardHealthcare CardPension Card

Please select *

GastroscopyColonoscopyBoth Gastroscopy & ColonoscopyConsult

Allergies / Adverse Reactions Details

Do you have any allergies/reactions

YesNo

Do you have any allergies/reactions to food or other substances

YesNo

Comment

Medications

Include all prescribed and over the counter medications you currently take in any form (eg tablets, liquid, drops, ointment, puffers, patches, injections, herbal preparations etc)

Medical History

Do any of the following apply to you? If Yes, please provide details and dates

Adverse reaction to an anaesthetic?Are you on Blood thinners?Heart condition Blood pressure problems Pacemaker or implanted defibrillator Blood clot in your lungs or legsSleep Apnoea, disturbed sleep, snoringLung or breathing problemsShortness of breath with normal daily activitiesLiver disease or problemsKidney disease or problemsHeartburn or refluxDiabetesEpilepsy, fits, blackouts, dizzinessMemory problems or dementiaMental health problems or diagnosisPhysical disabilityFall in the last 3 monthsLive in assisted care or nursing homeCould you be pregnantAny dental conditionsA diagnosis of CancerRequire Visual or hearing aids or prosthesisCurrent or past smokerDrink alcoholUse recreational drugs Any serious health problems not covered above

Comment

Please attach your GP referral

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Declaration of Patient/Parent/Guardian/Legal Representative

I agree that all information within this form is accurate and true, to the best of my knowledge

I have reviewed the SurfCoast Endoscopy Privacy Policy (SEPP) at https://www.surfcoastendoscopy.com/privacy-policy/and I consent to the collection and use of information I provide here and in the course of my engagement with SurfCoast Endoscopy Services. *

Date *

Patient's Signature *

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