Medical History Form
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Medical History Form
Confidential Medical History Form
Name
(Required)
First
Last
Gender
(Required)
Male
Female
Prefer Not Say
Date of birth
(Required)
DD slash MM slash YYYY
Occupation
(Required)
Address
(Required)
Street Address
Town
Post Code
Phone
(Required)
Email
(Required)
Doctor's Name and Address
(Required)
Are you currently receiving any medical treatment?
(Required)
Yes
No
Have you had any serious medical problems?
(Required)
Yes
No
Are you taking/ have taken steroids in the last 2 years?
(Required)
Yes
No
Are you taking any medicines or drugs from your doctor or self prescribed? (tablets, creams, ointments, injections, other). Please list.
(Required)
Yes
No
If yes, please bring a copy of your prescriptions with you.
Are you taking/ have taken steroids in the last 2 years?
(Required)
Yes
No
Have you received any radiotherapy?
(Required)
Yes
No
Are you allergic to any medicine, food or materials? (hayfever, eczema etc.)
(Required)
Yes
No
Do you suffer from asthma, bronchitis or chest infections?
(Required)
Yes
No
Have you had jaundice, hepatitis, liver or kidney disease?
(Required)
Yes
No
Do you have diabetes? If yes, how do you control your diabetes?
(Required)
I don't have diabetes
Diet controlled diabetes
Tablet controlled diabetes
Insulin controlled diabetes
Do you have bone or joint problems? (eg. arthritis)
(Required)
Yes
No
Have you high or low blood pressure?
(Required)
Yes
No
Have you any other heart problems such as angina, valve problems, heart surgery?
(Required)
Yes
No
Are you anaemic?
(Required)
Yes
No
Do you have any blood borne infections?
(Required)
Yes
No
Do you bleed a lot if cut, or bruise easily?
(Required)
Yes
No
Do you have epilepsy, or suffer from fits and faints?
(Required)
Yes
No
Have you received treatment for anxiety or depression?
(Required)
Yes
No
Do you smoke? If so, how many per day?
(Required)
Yes
No
How many units of alcohol do you have per week? (1 unit= small glass wine, ½ pint beer, 1 measure spirits.)
(Required)
None
Under 14 units
Over 14 units
Not sure
Your height
(Required)
Your weight
(Required)
Are you pregnant?
(Required)
Yes
No
Do you take oral contraceptives?
(Required)
Yes
No
Consent
(Required)
I consent
I consent to my GP being contacted for further medical information if and when required. I consent to photographs and x-rays being taken as required. I understand that these will be used for my clinical records.
Signature
(Required)
Signing as
(Required)
Myself
Parent/guardian of an under 16 year old
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