Albury Day Surgery Booking Form Patient Details Surgeon: Refer Dr: Procedure Date: Select Date Have you been admitted to Albury Day Surgery previously?: NoYes Year: Surname: Given Names: Previous Surname: Title: Mr Mrs Ms Miss Master Address: Date of Birth: Select Date Occupation: Home Phone: Work Phone: Mobile No: Marital Status: Single Married Widowed Seperated De Facto Country of Birth: Language used at home: English Are you an Aboriginal or Torres Strait Islander: Yes No Sex: FemaileMale Religion: Medicare No: Position on Card: Exp: January February March April May June July August September October November December     2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Person To Contact/Next of Kin Surname: Given Names: Address (if different from above): Home Phone: Work Phone: Mobile No: Relationship to Patient: Payment of Account Account Type: Please Select... Self (Uninsured) Health Insurance Veteran's Affairs Department of Defence Workers Compensation Third Party (TAC) Medical History Have you had any operations?: YesNo Have you had any illness or sickness recenty?: YesNo Are you on any current medication?: YesNo Are you on any alternative medicines?: YesNo Do you have a pacemaker?: YesNo Are you allergic to any drug, medicine or foods?: YesNo Have you ever had any treatment for excessive bleeding?: YesNo Have you or any of your relatives had any complications to anaesthetic?: YesNo Smoking: YesNo Alcohol: YesNo Are you pregnant?: YesNo Do you have any special dietary requirements?: YesNo Give Details: Please tick any of the following which you may have had: Heart Trouble Rheumatic Fever High Blood Pressure Asthma Stroke Deformity of neck or jaw Ankle or leg swelling Diabetes Epilepsy Tuberculosis Persistent cough Blood clots Arthritis Persistant bleeding Psychiatric Treatment HIV or AIDS Fits or faints Chest pain Hepatitis Submit