• Medical History Update Form

  • Date of birth (type in or use calendar)*
     - -
  • Location
  • 1. Do you have any problems with your heart, including high blood pressure or atrial fibrillation?*
  • 2. Do you have any problems with your breathing?*
  • 3. Are you epileptic or diabetic?*
  • 4. Have you ever been diagnosed with "weak" bones or osteoporosis?*
  • 5. Do you take regular medication?*
  • 6. Are you allergic to any medication (including penicillin) or to latex?*
  • 7. Do you have any other allergies?*
  • 8. Do you have any problems with your stomach when taking medication?*
  • 9. Have you ever had any problems with excessive bleeding?*
  • 10. Have you ever experienced cold sores on or around your mouth?*

  • (If yes, and you develop an active cold sore before your appointment, please contact the practice for advice prior to attending.)

  • 11. Are you pregnant or trying to conceive?*
  • 12. Have you ever had any form of cancer?*
  • 13. Have you ever had any major operations or serious illness?*
  • 14. Do you currently smoke, or given up recently?*
  • 15. Is there anything else about your medical history that you think we should know?
  • Should be Empty: