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  • Patient Details

  • Medical History Questions

  • Do you suffer from?

  • Any heart complaints? E.g. Heart Surgery, Angina, Heart attack, Pacemaker or other?*
  • High Cholesterol?*
  • Blood Pressure?*
  • Chest/Breathing problems? E.g. Asthma, COPD, Bronchitis etc.*
  • Diabetes?*
  • Epilepsy, seizures or Blackouts?*
  • Hepatitis/liver disease?*
  • Kidney Disease?*
  • Excessive Bleeding or Bruising?*
  • Blood Conditions E.g. Anaemia, Haemophilia?*
  • Mental health issues / depression / anxiety?*
  • Any other serious illness or infectious disease?*
  • Do you have any disabilities, mobility issues or sensory problems?*
  • Are you prone to fainting/fits?*
  • Gastointestinal, stomach or digestive problems?*
  • Have you ever had a stroke or a blood clot (thrombosis)?*

  • Do you...

  • Consume Alcohol*
  • Smoke or use an E-cigarette?*

  • Are you...

  • Allergic to Penicillin?*
  • Allergic to any medicines, tablets or materials? E.g. latex, rubber, plasters etc*
  • Has your GP advised you to avoid any medication?*
  • Taking the oral contraceptive pill? *
  • Pregnant or possibly pregnant?*
  • Due Date
     / /
  • Are you breastfeeding?*
  • Using any other prescribed medication?*
  • Using any self prescribed medication?*

  • In the past two years have you?

  • Undergone any operations?*
  • Date of operation
     / /
  • Been treated with hydrocortisone, corticosteroids or DMARDS?*
  • Date of treatment
     / /
  • Have you a bone/joint disease? E.g. Osteoporosis, arthritis etc*
  • Been treated with bisphosphonates? (bone tablets)*
  • Have HIV or any other blood-borne viruses? E.g. Hepatitis B or C*
  • Have you ever had a bad reaction to local/general anaesthetic?*
  • Been diagnosed with Cancer or had it in the past?*

  • Emergency Contact Details

  • In case of an emergency contact the person below

  • Medical history completed by?*
  • Should be Empty: