Medical History Form

Medical History Form
Full Name*

First NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Date
What is your sex at birth?*
What is your preferred gender?
What are your pronouns?
✓ Please tick all conditions that are applicable.
Heart Conditions:

High Blood PressureHigh CholesterolPrevious Heart Attack or SurgeryAnginaStrokeOther
Please provide details and/or approximate dates.
Respiratory Conditions:

AsthmaEmphysema/Chronic BronchitisOther
Please provide details and/or approximate dates.
Diabetes Conditions:

Type 1Type 2Other
Please provide details and/or approximate dates.
Have you had a diabetic review in the last year?

YesNo
Abdominal Conditions:

Ulcers/RefluxUlcerative Colitis/Crohn's DiseaseHepatitisDiverticulosisOther
Please provide details and/or approximate dates.
Cancer/tumors:

Melanoma CancerBreast CancerProstate CancerBowel CancerOther
Please provide details and/or approximate dates.
Bone Conditions:

OsteoporosisArthritisOsteoarthritisRheumatoid ArthritisOther
Please provide details and/or approximate dates.
Mental Health Conditions:

AnxietyDepressionBipolar DisorderSchizophreniaOther
Please provide details and/or approximate dates.
Other Conditions:

Eye DiseasesSkin DiseasesRheumatic FeverThyroid DiseaseEpilepsyOther
Please provide details and/or approximate dates.
Have you had any hospital admissions and/or surgery (prolonged admission or surgery only)?*

YesNo
Please provide details and/or approximate dates.
Are there any other medical conditions you'd like to tell us?*

YesNo
Please provide details.
Social Issues
Do you smoke?*

YesNo
How many cigarettes per day?
How long have you been smoking for?
Do you vape?*

YesNo
What is your vape juice strength?
Would you like assistance to give up? We have a free Health Coach at our clinic who supports patients with behavioural changes.

YesNoTell me more
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How many per week?
Do you use any kind of illegal drugs or have you ever used them?*

YesNo
What kind of drugs? How long have you used/been using them?
Family History
Please list any medical conditions from your direct family. Specific interest in cancers and/or cardiac conditions. (Please give as much information as possible)
Screening and Procedures
If you're over 25, when was your last smear?
Have you had any previous abnormal smear results?
When and where was your last mammogram done?
When was your last prostate blood test/exam?
Do you know if you had any childhood vaccinations?*

YesNoI'm not sure
Have you had any vaccines overseas?*

YesNoI'm not sure
If possible, please email us a copy of your overseas vaccinations to nurses@fourkauri.co.nz
Are you currently taking any medication?*

YesNo
Please list any current medications or bring them to your first appointment.
Do you have any medication allergies?*

YesNoNot Sure
Please list and describe reaction.
Would you like to see our Health Coach for free?

YesNoTell me more
Would you like to see our Health Improvement Practitioner for free?

YesNoTell me more
By clicking 'I Understand,' you confirm that you have read and understood the contents of this document. You also certify that the information provided is true and accurate to the best of your knowledge and that you are the individual named in this document or have the legal authority to act on their behalf.*

I Understand
Signed by*

PatientAuthorised Person
Name of authorised Person with legal right to sign for this patient:

First NameLast Name
Relationship:
Date*

DayMonthYear
Date
Should be Empty:

Medical History Form

Social Issues

Family History

Screening and Procedures