Medical Details

Details

Medical Details/History

Have you had a previous diagnosis of cancer?

 

Do you have heart issues?

 

If yes, please check:

 

Do you have lung or breathing problems?

 

Have you had any neurological problems? (eg. Stroke or seizure)

 

Do you have diabetes?

 

If yes, which type of current treatment:

 

Do you have high blood pressure?

 

Have you ever had any blood clots in your legs or lungs?

 

Do you have any autoimmune illnesses?

 

Do you have a blood or bleeding disorder?

 

Are you, or could you be pregnant?

 

Are you currently breastfeeding?

 

Have you had any of the following:

 

Do you smoke or have you ever smoked?

 

If yes, specify (approximately):

Do you drink alcohol?

 

Have been exposed to hazardous substances? (eg. asbestos, benzene etc.)

 

Your mobility:

 

Medications

Do you take any regular medication? (including herbal, or over the counter medications)

Allergies

Do you have any allergies or sensitivities to any medications, latex, food or other:

Family History

Do you have any family history of cancer?

 

If yes, specify

Past Surgery

Enter any previous operations you have had:

Harbour Cancer and Wellness

ABOUT OUR TEAM CONTACT PRIVACY POLICY

Wairau Clinic | Gate A, 212 Wairau Road, Wairau Valley, Auckland 0627
Newmarket Clinic | 105 Carlton Gore Road, Newmarket, Auckland 1023
T (09) 220 3333 | hello@harbourcancer.co.nz | harbourcancer.co.nz


southern cross health society logoAffiliated Providers 
We are an Affiliated Provider to Southern Cross Health Insurance for selected services. We also have relationships for direct billing with Accuro, AIA, NIB, Partners Life, Unimed, ACC and other insurers.

 


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