Medical History Form
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1NAME: ........................................................................
PT NUMBER:
Who is your doctor? Where is their practice?
YES
NO
DETAILS
1.Are you currently pregnant? Or had a baby in the last 12 months?
Due date:
Baby born on:
2.Are you currently receiving treatment from a doctor, hospital or clinic?
3.Do you suffer from allergies , including hay fever, eczema, any medicines (eg
penicillin), substances (eg latex/rubber) or foods? Please give details
4.Are you carrying a medical warning card?
5.Do you suffer from bronchitis, asthma or other chest conditions?
6.Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
7.Do you suffer from heart problems, angina, heart murmur, blood pressure
problems or stroke? Have you ever had rheumatic fever? Please give details
8.Are you diabetic (or is any blood relative)?
9.Do you suffer from arthritis?
10.Do you suffer from bruising or persistent bleeding following injury, tooth
extraction or surgery?
11.Do you suffer from any infectious diseases (including HIV and hepatitis)?
12.Have you ever had liver disease (jaundice) or kidney disease?
13.Have you ever had Blood Refused by the Blood Transfusion Service? If so why?
14.Have you ever had a bad reaction to general or local anaesthetic?
15.Have you ever had treatment that required you to be in hospital? Or any other
serious illness?
16.Have you ever had heart surgery or brain surgery? Which?
17.Do you have any close relatives (parent, sibling, child, grandparent or
grandchild) with Creutzfeldt Jacob Disease (CJD), or received growth hormone
treatment before the mid 1980s?
18.How many units of alcohol do you drink per week? (A unit is half a pint of lager,
Number of Units:
an single measure of spirits or a single glass of wine/aperitif)
19.Do you smoke any tobacco products now?
Times/day
20.Were you a smoker in the past?
Times/day
21.Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?
22.Do you take Bisphosphonate medication for your bones? Have you in the past?
Are you likely to in the future (for oesteoporosis / steroid use / bone cancer /
padjets disease) please list any meds below
23.If you are currently taking any medicines eg warfarin (for blood), bisphosphonates (for bones) please list below.
(This includes tablets, ointments, inhalers, contraceptives, HRT, self prescribed medication e.g aspirin)
PLEASE LIST ALL MEDICATIONS: (Please use the back of the sheet if necessary)
Email Address.................................................................................................................................
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Parent category: Medical