Medical History | Medic Scribble

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PATIENT FORMS
CONTACT

Your Background

Name*

Last name*

Address*

Date of Birth*

Occupation*

Phone

Email Address

Next of Kin

Next of Kin Contact Number

How did you hear about Dr. Ross Calopedos?*

Website

YouTube

Social Media

Referral from other health professional

Recommendation from existing patient

Name of Patient or Doctor who referred?

Reason for your visit*

Are you diabetic?*

Type 1

Type 2

Do you smoke or vape?*

Yes

Do you have a bleeding or clotting disorder?

Are you on any blood thinning medications?*

Aspirin

Plavix / Clopidogrel

Brilinta / Ticagrelor

Coumadin / Warfarin

Pradaxa / Dabigatran

Xarelto / Rivaroxaban

Eliquis / Apixaban

Do you have any cardiovascular problems?

Have you a stent(s) put in your blood vessels?

Other cardiac procedures, tick those relevant to you

Pacemaker insertion

Defibrillator insertion

Coronary bypass surgery (CABG)

Heart valve replacement

What is the name of your cardiologist / cardiothoracic surgeon?

Have you ever had a stroke or TIA?

Yes

Do you have or take medications for high blood pressure?

Yes

Asthma?

Yes

Kidney disease?

Yes

Liver disease?

Yes

Do you have obstructive sleep apnoea?

Suspected (I snore loudly at night)

Yes, I've been formally diagnosed with a sleep study

If relevant, how are you managing your sleep apnoea?

Have you previously had a joint replacement?

Yes

Do you have any back problems or have you had a spinal cord injury or surgery?

Do you have or have you been diagnosed with any neurological problems?

Have you ever needed treatment for a stomach or duodenal ulcer?

Have you ever been diagnosed with or received treatment for any sort of cancer?

List any allergies you have

Other medical problems not captured above?

Current medications

Previous surgery / operations / procedures

Please complete the questionnaire to the best of your ability. The information you provide serves as a guide for your upcoming consultation with Dr. Ross and ensures continuity of care and information throughout your assessment.

Streamlined Pre-consult Information

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