Patient Medical History Form

Please click on the link below to download a copy of the Patient Medical History form. Please complete the form and bring it along to your appointment.

Patient Medical History Form

Alternatively, forms can be forms can be faxed to (02) 9262 9597, emailed to info@vintagesurgicalspecialists.com or posted to: 

Vintage Surgical Specialists
Unit 3, The Vintage,
281-287 Sussex St
Sydney NSW 2000

 

Alternatively, fill out the form below:

Patient Information



















Hospital Cover

Yes No

Dental Cover

Yes No





Medical History

Are you under the care of your doctor at present?

Yes No

Are you taking any tablets or medicines at the moment?

Yes No


Have you ever been treated for osteoporosis?

Yes No

Have you ever taken any of the following drugs:

Fosamax
Actonel
Skelia
Didronel
Aredia
Zometa
Bonefos

Are you allergic to any medications or other substances?

Yes No

Have you been in hospital during the last 2 years?

Yes No

Do you smoke?

Yes No

Ladies, are you, or might you be pregnant?

Yes No

If you have, or have had, any of the following conditions please place a tick in the box.


I have further confidential medical information which I do not wish to write down.

Yes No

I have completed this form to the best of my knowledge and it represents my medical history accurately. Any changes will be advised at subsequent appointments.

I agree to be a private patient of this practice and pay the appropriate quoted fee including any collection fees.