Medical History Please fill in the form below, or download it from here PATIENT DETAILSPatient Name* First Last Patient's Home Address* Street Address ZIP / Postal Code Tel. No (Home)*Tel. No (Mobile)*Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Doctor's Name and AddressDoctor's Name* First Last Doctor's Address* Street Address ALLERGIESDo you have any allergies?*YesNoAllergies*MEDICAL CONDITIONSDo you have any medical conditions?*YesNo, not that I know ofMedical Conditions* ADHD Behavioural Disorder Asthma Anaemia Anxiety, Mood Swings, Panic Attacks or Depression Arthritis Autism Bipolar Blood or Bleeding Disorder Broken Bones Bronchitis or other Chest Complaint Cancer Carry a Medical Warning Card or Bracelet Cochlear Implant Communication Difficulties Diabetes Eating Disorders or Weight Issues Eczema Endocrine Disorder Fainting Spells, Dizziness or Vertigo Gallbladder Disease eg. Gallstones Glaucoma Gout Hearing Impairment Heart Condition, including Heart Murmur High Cholestrol High Triglycerides High or Low Blood Pressure Infestious Disease (including HIV and Hepatitis) Kidney Disorder Learning Disability Neuromuscular Disorder Liver Disease Migraine or Chronic Headache Mobility Issues Pacemaker Pregnant or Possibly Pregnant Receiving Treatment from Hospital Doctor or Clinic Shortness of Breath Sinus Problems Skin Condition Sleep Problems Speech Impairment Stomach or Intestinal Problems Taking Any Prescribed / Non Prescribed Medication Thyroid Disorder Undergone an Operation in the Last Two Years Visual Impairment Any Other Condition not listed here Other medical condition*Other notesPatient Confirmation* I confirm the contents of this Medical History are correct
