Patient Medical History Form
Title__________________________________________________________________________________
Surname_______________________________________________________________________________
Forename______________________________________________________________________________
Address_______________________________________________________________________________
______________________________________________________________________________________
Date of birth____________________
Tel no (home) __________________
Business________________________________________
Mobile________________________
E-mail__________________________________________
Questions
Yes
No
Are you currently pregnant?
Do you carry a medical warning card?
Are you receiving treatment from a hospital or a clinic?
Do you suffer from hay fever or eczema?
Do you suffer from bronchitis, asthma or other chest conditions?
Are you allergic to any medicine, tablets, substances or latex?
At present taking any medicine or tablets? (list below in notes)
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
Do you suffer from heart problems, angina, blood pressure problems, or stroke?
Are you diabetic?
Do you suffer from arthritis?
Do you suffer from bruising or persistent bleeding following injury, tooth
extraction or surgery?
Do you suffer from any infections diseases (including HIV and hepatitis)?
Have you ever had rheumatic fever or chorea?
Have you ever had liver disease or kidney disease?
Have you had any other serious illness?
Have you ever had a bad reaction to general or local anesthetic?
Have you ever had a joint replacement or other implant?
In the past 2 years have you undergone any operations?
Have you ever been treated with hydro-cortisone or corticosteroids?
Do you smoke?
What is your average weekly consumption of alcohol?
G.P./Doctor’s Name and Address
_____________________________
Notes
________________________
_____________________________
________________________
Patients Signature______________________
Date_____________________
How did you hear about us?:
_______________________________________________