Your Medical History Name * First Name Last Name Sex * Male Female Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Occupation NHS Number If known Insurance Provider If you have one Other contact details: In the event of an emergency, please contact: Name * First Name Last Name Phone * (###) ### #### Relationship to you * Doctors Details Doctors Name Doctors Phone (###) ### #### Practice's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are you currently: Check all that apply Receiving treatment from a doctor, hospital or clinic? Taking any prescribed medicines? Carrying a medical warning card? Have you ever had: Check all that apply Allergies to medicines, substances or foods? Bronchitis, asthma or other chest condition? Fainting attacks, giddiness, blackouts, epilepsy? Heart problems, angina, blood pressure problems, or stroke? Diabetes (or does anyone in your family)? Bone or joint disease? Bruising or persistent bleeding following injury, tooth extraction or surgery? Liver disease (eg jaundice, hepatitis) or kidney disease? Any other serious illness or infectious disease? Blood refused by the Blood Transfusion Service or any other agency abroad? A bad reaction to general or local anaesthetic? Treatment that required you to be in hospital? Heart surgery or a stent? Any form of mental illness (e.g. depression, anxiety, stress, eating disorders) ? Personal habits: How would you describe your consumption of alcohol? Non-drinker Modest Moderate More than I should Heavy Do you consume any tobacco products now (or, did you in the past)? Yes No Past Thank you!
