COVID 19 Information
The following questions are designed to keep the hospital, patients and staff as free as possible from COVID-19. It is essential you answer them as truthfully as possible. We will be happy to discuss your concerns.
Have you currently or in the previous 14 days had a temperature, cough, muscle pains, malaise, shortness of breath, loss of taste or smell, nose bleed, abdominal pain or diarrhoea?*
Has anyone in your household or anyone you have been in close contact with had any of the above symptoms within the last 14 days?*
Have you worked outside of your home in the last 14 days?*
Have you travelled on public transport in the last 14 days?*
If you answered yes to the above question please choose which mode of transport you have used.
TubeBusRailPlaneBlack CabOther Taxi
Have you visited a hospital, GP surgery or care home in the last 14 days?*
Have you had a PCR (nasal and throat swab) test for COVID-19?*
If you answered yes to the above question please state when, why and what the result was from the test.
If you use a COVID-19 app, have you had any alerts in the last 14 days?*
Is there any other reasons you believe you may have contracted or been exposed to COVID-19 in the last 14 days?*
If you answered yes to the above question please give a detailed explanation.
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: