Medical History Form

Medical History Form
Patient's Name*

First Name Last Name
Address*
Date of birth*

DayMonth 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 FeverHigh Blood PressureHeart SurgeryPacemaker FittedHeart MurmurThrombosisNone
Other Heart Conditions:

Chest Problems :-

BronchitisEmphysemaPneumoniaChest SurgerySmokerCystic FibrosisPleurisyNone
Other Chest Conditions:

Blood Problems :-

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

Other issues :-

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

Allergies :-

PenicillinHay FeverAnti-Tetanus Serum.EczemaAspirinAsthmaticLatex AllergyNone
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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