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

Northern Clinic - Southern Cross North Harbour Campus | Gate A, 212 Wairau Road, Wairau Valley, Auckland 0627

Newmarket | 105 Carlton Gore Road, Newmarket, Auckland 1023
T (09) 220 3333 | info@harbourcancer.co.nz | harbourcancer.co.nz


southern cross health society logoAffiliated Providers 
Harbour Cancer & Wellness is affiliated with Southern Cross Health Insurance.
We also have affiliated provider relationships for direct billing with NIB, AIA, Accuro, Partners Life and Unimed.

 


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