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