Medical 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:



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


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 & Wellness provides essential health services at all COVID-19 alert levels.

We are very focused on providing a safe environment for patients in our facilities: Clinic, Day-Stay and in the Wellness Centre.

To discuss a referral or treatment, call our main line on 09 220 3333.

Wellness services are available at Level 3 - phone DDI: 09 925 4451 / email

Take care, everyone

Harbour Cancer & Wellness team