Patient Number

Your weight (Kg)

Your height (metres)

Do you suffer from, OR Have you ever suffered from any of the following?

Heart disease

High blood pressure

Lung disease

Obstructive sleep apnoea

Indigestion

None

Do you smoke?

No

Yes

Do you drink alcohol?

No

Yes

Do you have allergies to medications, tablets, plasters, food, LATEX or any other substance?

No

Yes

If Yes, please provide details below.