Are you suffering from T.B. / Have you ever had it ?
Are you asthmatic / Do you have difficulty breathing ?
Any disease involving kidneys ?
Have you ever had Jaundice / Hepatitis ?
Have you ever had a Stroke / paralysis ?
Do you smoke / have you been smoking in the past? Number of cigarettes / day ?
Is your Cholesterol level higher than normal ?
Are you overweight ?
Do you have a family history of high Blood pressure/Diabetes/Heart disease or Stroke ?
Have you had any surgeries in the past ?
Your blood group (if known):
Any history of Blood transfusions in the past ?
Any known allergies to drugs/foods etc. ?
Any other relevant information you believe would be helpful?
CONSENT FOR TREATMENT
I hereby willingly consent to treatment at Tahir Heart Institute. This consent covers any treatment regarding medications, anesthesia, surgical procedures, nursing and other care given in this facility.