Please provide your mobile number *
Proposed Operation *
Under which surgeon? *
Date of Operation (dd/mm/yyyy) *
Your insurance company if you are claiming fees back
Obstructive Sleep Apnoea
Do you have Obstructive Sleep Apnoea or snore? *
Have you ever had pancreatitis?
Please include cysts and pancreatic cancer *
Please provide as much information as possible.
Medication and Drugs
Are you taking any medication? Have you taken steroids in the last three months?
Please include over the counter and recreational drugs, vitamins and Chinese herbs *
Please list all the drugs you are taking.
The dosage would be helpful, especially if you are on insulin
Are you allergic to any drugs, medicines, foods or LATEX
Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock *
Please provide details.
Please tell me the name of the drug or allergen and what reaction you had. Your GP may be able to assist you if you cannot remember.
Have you had falls? *
Do you have mobility problems or need mobility aids? *
Do you have a needle phobia? *
If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below: