MACKIE ROAD CLINIC - NEW PATIENT MEDICAL INFORMATION
PATIENT NAME:__________________________________
D.O.B.:________________
PREVIOUS MEDICAL CONDITIONS: Please tick if you have a history of, and indicate dates if possible:
Operations_________________________________________________________________________________
_____________________________________________________________________________________________
Asthma____________________________________________________________________________________
Diabetes___________________________________________________________________________________
High blood pressure_________________________________________________________________________
Chronic illness______________________________________________________________________________
Other_____________________________________________________________________________________
MEDICATIONS: Name & dose, including over the counter medications, vitamins & minerals
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
ALLERGIES/SENSITIVITIES:___________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PREVIOUS IMMUNIZATIONS: Are they up to date? Please indicate type & date given if known:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DO YOU HAVE A FAMILY HISTORY OF: (please tick if yes)
Diabetes
Heart Disease
Cancer
Psychiatric illness
Other_____________________________________________________________________________________
BLOOD PRESSURE: Please indicate reading & date last taken if known:
____________________________________________________________________________________________
SOCIAL HISTORY: Please tick if you:
Smoke -
____ /day
Drink Alcohol -
or
Ceased Smoking -
Date ______________________
____ drinks per day/week/month (circle the one applicable)
Use Recreational Drugs – give details____________________________________________________________
Do regular exercise for health
PATIENTS OVER 45 YEARS OF AGE:
Have you had a recent health check, including blood tests?
Yes
No
FEMALES : WHEN DID YOU LAST HAVE:
Pap smear
Date______________________
Not sure
Never
Breast check
Date______________________
Not sure
Never
PLEASE HAND THIS SHEET TO YOUR DOCTOR
0
