Medical History Form

Medical History Form
Patient's Name*
Address*
Date of birth*

DayMonthYear
Home Phone*
Mobile Phone
Doctor's Name*
Practice Name*
Practice Phone
Emergency Contact*
Emergency Phone*
Relationship to patient

Do you

have or have you had any of the following conditions? (tick all that apply)
Heart Problems :-

Rheumatic FeverHigh Blood PressureHeart SurgeryPacemaker FittedHeart MurmurThrombosis
Other Heart Conditions:

Chest Problems :-

BronchitisEmphysemaPneumoniaChest SurgerySmokerCystic FibrosisPleurisy
Other Chest Conditions:

Blood Problems :-

BleedingHepatitis BH.I.V.AnaemiaAbnormal Blood TestSickle CellHaemophiliaTB
Other Blood Conditions :-

Other issues :-

Serious Childhood IllnessDiabetesLiver Disease.Kidney DiseaseEpilepsyCancerG.A. ExperienceHiatus Hernia
Other Conditions :-

Allergies :-

PenicillinHay FeverAnti-Tetanus Serum.EczemaAspirinAsthmaticLatex Allergy
Other Allergy Conditions :-

Warnings :-

Reaction to local anaesthetic?Anti biotic cover required?Problem being reclined?.Are you pregnant?Do you carry a warning card?Artificial or prosthetic joint?
What special precautions should we take?

List any medications you're taking :-
Signed by: Date:
Signed by:
Date:

MonthDayYear
Date
Should be Empty: