Medical History Form

We ask you for information about your general health to help us treat you safely. Please fill out your contact details below, answer the health questions and then accept the terms in the last section. We will use this form at later visits to discuss any change in your general health. All information will be kept strictly confidential by the people caring for you.

Medical History

Please answer all the below questions by ticking ‘yes’ or ‘no’. If you answer ‘yes’ to any questions please provide additional details in the
space indicated. All information provided will be kept strictly confidential.

Are you currently:

Prescription Medications:

Please list any prescription medications, non-prescription medicine, herbal treatments or supplements you are taking

Allergies:

Do you have allergies to any of the following?

Have You Ever Had Any of the Following?

Alcohol Usage:

(A unit is half a pint of lager, a single measure of spirits or a single glass of wine/aperitif)

Tobacco Usage:

Further Medical Information