GP Form

Medical Assessment Form

Patient Photo

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 20 MB.

Patient Number *

Family Name: (KH/EN) *

Given Name/s: (KH/EN) *

Medical History (Please Check)

Heart Disease Including

Hypertension

Yes No

Chest Pain

Yes No

Shortness of breath

Yes No

Other cardiovascular Notes

Respiratory History Including

Asthma

Yes No

Cough

Yes No

COPD

Yes No

Other respiratory Notes

Metabolic History Including

Diabetes

Yes No Unknown

Thyroid Disease

Yes No

Kidney Failure

Yes No

Other metabolic Notes

Infections Including

Other Infectious Disease Notes

Additional History

Tests

O2 Saturation

Temperature

Fasting Glucose

B.P.

Pulse Rate

Heart Sound

WE WILL NOT OPERATE ON PATIENTS WITH A B.P. OF SYSTOLIC ABOVE 180 OR DISTOLIC ABOVE 140 mmHg or Fasting Glucose above 14 mmol/L

Other tests

CXR

No Yes

E.C.G.

No Yes

Blood test

No Yes

Other Findings

Clinical Examination

CVS

No Yes

Respiratory

Normal Not Normal

Anaemic/Jaundice

No Yes

Summary

Can Patient Lay Down Flat For One Hour

YES NO

Surgery Status *

PATIENT IS FIT FOR SURGERY PATIENT IS NOT FIT FOR SURGERY PATIENT REFUSED SURGERY FIT FOR SURGERY - DID NOT SHOW UP

Has The Patient Signed The Consent Form *

YES NO

Has The Patient Had Their Photo Taken And Saved *

YES NO

Date