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Forms Background Medical History

Consultation Background Medical History Form

Questionnaire to insure we understand your medical history

Your backround medical data is essential to providing you with safe and relevant management options whether conservative or surgical. If all data is not disclosed then we cannot be held responsible for outcomes relating to missing information.

- Step 1 of 2

Name *

First

Last

Date of Birth *

Today's date *

Do you have any of the following medical problems?

High Blood Pressure *

Yes
No

ICD-10 Code: I 10

Diabetes on Insulin *

Yes
No

ICD-10 Code: E 10

Diabetes on oral meds only *

Yes
No

ICD-10 Code: E 11

Hypothyroidism *

Yes
No

ICD-10 Code: E 03.9

Heart disease *

Yes
No

ICD-10 Code: I 25.9

Osteoporosis *

Yes
No

ICD-10 Code: M 81.5

Gout *

Yes
No

ICD-10 Code: M 10.9

Parkinson’s *

Yes
No

ICD-10 Code: G20

Epilepsy *

Yes
No

ICD-10 Code: G40

Depression *

Yes
No

ICD-10 Code: F 33.9

Breast Cancer *

Yes
No

ICD-10 Code: C 50.9

Prostate Cancer *

Yes
No

ICD-10 Code: C61

Other Cancer *

Yes
No

ICD-10 Code: C80.9

Disease Affecting Immune System *

Yes
No

ICD-10 Code: B24

Rheumatological Disorder *

Yes
No

ICD-10 Code: M06.9

Renal failure *

Yes
No

ICD-10 Code: N19

Do you have any of the following conditions?

On a blood thinning agent *

Yes
No

Have you had heart surgery *

Yes
No

Have you had lung surgery *

Yes
No

Have you had peripheral joint surgery *

Yes
No

Have you had spine surgery *

Yes
No

Have you had abdominal surgery *

Yes
No

Do you smoke currently *

Yes
No

Have you ever been a smoker *

Yes
No

Do you have an allergy to ANY medication that you are aware of *

Yes
No

Have you or a family member had Deep Vein Thrombosis *

Yes
No

Details: of Meds and/or other yes answers:

Comment

Book a Consultation:

Personal Assistant to Dr Munting

Merle Hermanus

+27 21 424 0725/6

merle@ctorth.com

Settle my Account:

Accounts & Admin

Jami Damon

+27 21 424 0726

jami@ctorth.com

Find Us:

Netcare Christiaan Barnard Memorial Hospital

25 D.F. Malan St, Foreshore,

Cape Town, 8001

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