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Form Information

Thank you for visiting Ramsay Health Care UK. Can you please take the time to carefully complete your details on the following form.

Ramsay Health Care UK Operations Limited (“Ramsay”) is committed to ensuring the privacy and confidentiality of your personal information, and to protect it from unauthorised access and disclosure.

In order to provide you with accurate and timely information about your appointments and treatment with us, we will need to contact you, and ensuring we use the best method of communication is vital.

If you have provided a mobile telephone number, you will receive a reminder regarding your upcoming appointments. You are able to ‘opt out’ of this service by following the instructions on your message.

For more information on how we use your data, please visit our Privacy Policy (please copy link:https://www.ramsayhealth.co.uk/privacy-policy).

How is your treatment being funded?(Required)

Patient Information

Which number is this?(Required)
Which number is this?
Which number is this?
Will this address be your address on discharge?(Required)
Do you/the patient have any disabilities?(Required)InfoRamsay Health Care UK has a responsibility to ensure that the services provided to patients are done so in an equitable and fair manner. Understanding our patients' needs helps us to ensure we comply with those important obligations.
Are you hard of hearing?(Required)
Are you visually impaired?(Required)
Do you live alone?(Required)
Any dependants?(Required)
Do you have any concerns about your safety at home?(Required)
Do you have any communication problems or special learning needs?(Required)
Is English your first language?(Required)

Emergency Contact Information

Same Address as Patient
Which number is this?(Required)
Which number is this?
Which number is this?
Would you like to register an alternative emergency contact?
Same Address as Patient
Which number is this?(Required)
Which number is this?
Which number is this?
Is there anyone you do NOT wish us to discuss your care with, if asked?(Required)

Visit/Admission Information

Is the date of visit known?(Required)
Is consultant's name known?(Required)
Have you; or has the patient previously attended this hospital for care?(Required)

How we communicate with you

To share information about appointments and your treatment To share information about Ramsay Healthcare and it's services Action
Email
SMS Message
Home Telephone
Can we leave a voice mail?
Mobile Telephone
Can we leave a voice mail?
Work Telephone
Can we leave a voice mail?
indicates required field
Do you require any additional support with communication?(Required)
If yes to the above: Please select all the communication needs which apply

We will only send you marketing information where you have agreed to opt in to receive it. We will only use your preferred communication channels to contact you and you will be given the option to select this when opting in. You can stop us from contacting you for marketing purposes by clicking on the ‘unsubscribe’ link embedded within the email that has been sent to you. Doing so will remove your personal data from our contacts list automatically.

We will always try and use your preferred method of communication, however, there may be instances when we use another of your consented communication options.

Information about your health

Please note: we ask some questions which relate to a family history / first degree relative. We appreciate that some patients may have been adopted or cared for, without medical information on their biological parents.

I can confirm that I do not have access to information concerning biological parent(s)/first degree relative(s) medical history:(Required)

Health and Social History

If you have been given your admission date, do you intend undergoing any form of continuous travel (e.g. car, train, plane) of more than 3 hours approximately 4 weeks before or after surgery?(Required)

Previous Anaesthetics

Have you ever had problems with a previous anaesthetic?(Required)
Have any of your relatives had problems with anaesthetics?(Required)

Allergies

Have you ever had a reaction to medicines or other substances (e.g. food/topical agents/latex/metal/other)? if 'yes', give details of what medicine(s)/substance(s) were involved(Required)
What have you reacted to? What was the Reaction? Action
indicates required field

Alcohol,Smoking/Vaping and Exercise

Do you drink alcohol? (Required)
Would you like to receive some advice on how to reduce your intake of alcohol?(Required)
Do you smoke at present, or have you ever smoked?(Required)
Do you vape at present, or have you ever vaped?(Required)
Would you like to receive some advice on how to give up smoking/vaping?(Required)
Do you take regular exercise?(Required)
Would you like to receive some advice on healthy eating and exercise?(Required)

Medication

Are you currently taking any form of medications (prescribed, weight loss, herbal, vitamins, recreational drugs or other)?(Required)
Provide details of medicine name, frequency and when you last took it: Medication name, When Taken, Dosage
Medication Dose How often do you take it? Action
indicates required field
If taking steroids, do you have a Steroid Card?(Required)
In the last 12 months have you taken any medicine for cough, cold or flu containing Pholcodine? (If unsure, hospital will check)(Required)

Heart Disorders

Do you get chest pain or breathless climbing two flights of stairs?(Required)
Do you suffer with angina more than once each month?(Required)
Have you ever had a heart attack?(Required)
Are you currently being treated for an abnormal heart beat?(Required)
Are you currently being treated for heart failure?(Required)
Have you ever been told that you have a heart murmur?(Required)
Are you being treated for high blood pressure?(Required)
Do you have a cardiac pacemaker or internal cardiac defibrillator?(Required)
Do you have coronary stents(Required)

Breathing disorders

Do you have asthma, emphysema, chronic bronchitis or any other breathing disorder, including sleep apnoea, cystic fibrosis?(Required)
If you have Asthma do you have attacks more than once per month?(Required)

Brain and neurological disorders

Have you been diagnosed as having epilepsy?(Required)
Do you have Parkinsons disease, motor neurone disease, MS, cerebral palsy.(Required)
Do you suffer from fainting, falls or blackouts?(Required)
Have you ever had a transient ischaemic attack (TIA) or stroke?(Required)
Do you have a history of Creutzfeldt-Jakob (CJD) or other prion disease?(Required)
Have you ever had surgery on your brain or spinal cord? (Required)
Have you ever received growth hormone or gonadotrophin treatment?(Required)
Was the hormone derived from human pituitary glands?(Required)
Do you suffer with confusion or dementia or have you been diagnosed with Alzheimer's.(Required)

Stomach and gut disorders

Do you suffer regularly from indigestion or heartburn?(Required)
Have you ever been treated for a stomach ulcer or hiatus hernia?(Required)
Do you suffer from a bowel condition, e.g. chronic constipation (state laxatives taken) or irritable bowel syndrome or inflammatory bowel disease such as Crohn's disease or ulcerative colitis,or have a stoma?(Required)

Hormone disorders

Do you have diabetes?(Required)
Do you have thyroid disease?(Required)

Liver disorders

Have you ever had jaundice (yellowness of the skin)?(Required)
Have you ever been diagnosed as having hepatitis?(Required)

Bleeding disorders

Have you ever had a blood transfusion? (Required)
Have you ever been issued with an antibody card?(Required)
Do you refuse to receive blood or blood products?(Required)
Do you bleed or bruise very easily?(Required)
Have you ever been diagnosed as having a blood clot in the leg (deep vein thrombosis) or in the lung (pulmonary embolus)?(Required)
Has a first-degree relative ever been diagnosed as having a a blood clot in the leg (deep vein thrombosis) or in the lung (pulmonary embolus)?(Required)
Have you ever been diagnosed with any inherited blood disorder such as sickle cell disease or clotting disorder?(Required)
Have any close relatives been diagnosed with any inherited blood disorder such as sickle cell disease or clotting disorder?(Required)
Have you ever been anaemic?(Required)

Musculoskeletal disorders

If you sit upright in a chair, do you have difficulties putting your head back far enough to see the ceiling directly above you, while keeping your back straight?(Required)
Have you or a family member ever been diagnosed as having an inherited muscle disease?(Required)
Have you been diagnosed as having arthritis?(Required)
Do you use a mobility aid (e.g. sticks or walking frame)?(Required)

Urinary and renal disorders

Have you ever been diagnosed with or treated for acute or chronic kidney disease?(Required)
Are you currently being treated for a urine infection?(Required)
Do you use a urinary catheter?(Required)

Skin disorders

Do you currently have any open wounds/ulcers/blisters?(Required)

History of Cancer and/or Transplant

Have you ever been diagnosed as having any type of cancer?(Required)
Have you had an organ/ tissue transplant or stem cell transplantation?(Required)

Previous operations

Have you ever had an operation? (Required)
Procedure Year Action
indicates required field

Other medical conditions

Is there any other medical or physical condition, not previously mentioned, eg long COVID, renal dialysis, Downs Syndrome, CPAP, oxygen therapy.(Required)
Do you have a recent history of dental abscess or infections?(Required)
Do you suffer with any anxiety or mental health problems?(Required)
Do you take any medicines to treat chronic (long-term or complex) pain? This may include fentanyl patches, morphine or medical cannabis. (Our pharmacy team may need to ask further questions in relation to pain management)(Required)

Infection risks

Have you ever suffered a serious infection (e.g. sepsis, clostridium difficile, food poisoning, diarrhoea)? (Required)
Have you ever been colonised with MRSA or diagnosed with a MRSA infection (Required)
In the last 12 months have you been an inpatient in a UK hospital? (Required)
In the last 12 months have you been an inpatient in a hospital abroad/outside of the UK? (Required)
Have you, or a close contact of yours, been colonised or had an infection with Carbapenemase-producing Enterobacteriaceae (CPE)?(Required)
Are you or could you be pregnant?(Required)
Are you currently breast-feeding?(Required)
Do you take the oral contraceptive pill, take oral HRT, use hormone creams/pessaries or have hormone / contraceptive implants? (Required)

Consent

What is your relationship with the patient?(Required)

By clicking submit, I agree that the signature will be the electronic representation of my signature for all submissions of my registration form - just the same as a pen-and-paper signature.

I have read and agree with the above statement.

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