Pre-Surgery Health Questionnaire

Has a doctor ever told you that you have a long-term health condition?

Choose one:

• Yes
• No

Which long-term condition or conditions have you been diagnosed with?

Condition: Only for patients with a diagnosed condition

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Are you currently taking any medicine prescribed by a doctor?

Choose one:

• Yes
• No

Please list each medicine you take, with the dose if you know it.

Condition: Only for patients taking prescribed medicine

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How physically active are you at the moment?

Choose one:

• Inactive
• Lightly active
• Moderately active
• Very active

In a typical week, on how many days do you have each of the following?

• Fast food or takeaway meals
• Fruit or vegetables
• Alcoholic drinks
• Cigarettes or other tobacco
• Processed foods such as ready meals or packaged snacks

For each row: choose one:

• Never
• 1-2 days
• 3-4 days
• 5-6 days
• Every day

Do any of these conditions affect your parents, brothers, sisters or children? Select all that apply.

Choose any that apply:

• Heart disease
• Diabetes
• High blood pressure
• Cancer
• Arthritis
• None of these

Are there other important health conditions in your close family that are not listed above? (optional)

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Have you recently noticed any unusual physical symptoms, for example pain, tiredness or poor sleep?

Choose one:

• Yes
• No

Please describe these symptoms and when they started.

Condition: Only for patients reporting symptoms

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