New Patient Medical Information

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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
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