Interpreter RequiredYesNo
Private InsuranceYesNo
What medical problems have you had in the past and around when were they diagnosed?
Asthma
Emphysema / COPD / Bronchitis/Bronchiectasis / Interstitial Lung Disease
Sleep apnoea
Other lung disease & Tuberculosis
Diabetes
Neurological Diseases / strokes
Sinus disease
High Cholesterol
Reflux & stomach ulcers
Cancer
Heart Disease / Arrhythmias
Kidney Disease
Others
Have you ever smoked?YesNo
How many standard drinks of alcohol would you consume on average per day?01 – 23 – 4>4
Are you up to date with your cancer screening tests (e.g. breast, prostate etc)?YesNo
Have you had the ‘flu’ vaccine in the last year?YesNo
Have you had the ‘pneumonia’ vaccine in the last five years?YesNo
