Medical History Form

Medical History Form
Patient's Name *

First Name Last Name
Address *
Date of birth *

Day Month Year
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 Fever High Blood Pressure Heart Surgery Pacemaker Fitted Heart Murmur Thrombosis None
Other Heart Conditions:

Chest Problems :-

Bronchitis Emphysema Pneumonia Chest Surgery Smoker Cystic Fibrosis Pleurisy None
Other Chest Conditions:

Blood Problems :-

Bleeding Hepatitis B H.I.V. Anaemia Abnormal Blood Test Sickle Cell Haemophilia TB None
Other Blood Conditions :-

Other issues :-

Serious Childhood Illness Diabetes Liver Disease. Kidney Disease Epilepsy Cancer G.A. Experience Hiatus Hernia None
Other Conditions :-

Allergies :-

Penicillin Hay Fever Anti-Tetanus Serum. Eczema Aspirin Asthmatic Latex Allergy None
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? None
What special precautions should we take?

List any medications you're taking :-
None
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Date:

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