Following the lifting of restrictions by the Government, we would like to reassure all our patients that the way we interact with you will not be changing. All staff and consultants will continue to wear face coverings and maintain social distancing, and we require our patients and visitors to do the same, so that we are all protected.

More Information

Need Help?

If you need any help completing your form please email Ramsay.Digital@ramsayhealth.co.uk and we will be happy to help.

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Form Information

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Your Details

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Past Medical History

Medical Questionnaire

Thank you for visiting Ramsay Health Care UK medical questionnaire. Can you please take the time to carefully complete your details on the following medical questionnaire. It should take a maximum of 25 minutes to complete.

  • 1) The Hospital you will be treated at
  • 2) The name of your Consultant
  • 3) Your GP information
  • 4) Your insurance company details
  • 5) Your insurance policy number
  • 6) Your authorisation number
  • 7) Your NHS number will also be helpful but not essential
  • 8) Patient Number (found on your correspondence from us)

Please ensure you have this information readily available as you will need to complete the form in one session and will not be able to save and return later to complete the form.

Medical Questionnaire

The following questions help us to decide whether we need to see you for a pre-operative check before you are admitted to our hospital. If you need help completing the form or are unsure of the meaning of any of the questions, the please contact the hospital for advice.

Please complete the questionnaire fully (giving any further details you feel may be helpful), and return to the hospital within 48 hours, or as instructed by the hospital staff.
NB Delay in returning this form may result in delay of surgery booking.

Personal Details

Next of Kin Information

Second Contact Information

Past Medical History

Please complete the following medical questions as accurately as possible. This is important because it enables us to be informed of any special medical needs you may have and ensures that you are safely prepared for your anaesthetic.

Please tick yes or no to the following questions and give further details you think may be helpful to us.

Previous Anaesthetics

Allergies

Alcohol, Smoking/Vaping and Exercise

Medication

Heart Disorders

Breathing Disorders

Brain and Nerve Disorders

Stomach and gut Disorders

Hormone Disorders

Liver Disorders

Bleeding Disorders

Musculoskeletal Disorders

Urinary and Renal Disorders

Skin Disorders

Further Disorders/Symptoms


Previous Operations


Other Medical Problems

Infection Risks


Female patients only

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By clicking submit, I agree that the signature above will be the electronic representation of my signature for all submissions of my registration and medical questionnaire form - just the same as a pen-and-paper signature.

Thank you for providing your information

We will get back in touch if there is anything we need to clarify.

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