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Medical History

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Date of Birth DD/MM/YYYY (e.g 18/05/1985)

Do you consent to receiving reminders and information about: (DE-SELECT THE ONES YOU DO NOT CONSENT) Required

ARE YOU; OR HAVE YOU HAD ANY OF THE FOLLOWING:

Attending/Receiving treatment from a G.P or hospital?
Allergic to any medicines, foods or materials?
Ever had Rheumatic Fever or Chorea?
Ever been told that you have a heart murmur, heart problem, angina, high blood pressure, or heart attack.
Had jaundice, liver, kidney disease or hepatitis?
Had any infectious diseases [including hepatitis or HIV]?
Had a bad reaction to local or general anaesthetic?
Been hospitalised in the past 2 years? If yes what for and when?
Had a hip / joint replacement?
Been Advised that you need antibiotic cover?
A pacemaker or had any form of heart surgery?
Suffer from bronchitis, asthma or any other chest condition?
Suffer from hay fever, eczema or any other allergy condition?
Had fainting attacks, giddiness, blackouts or epilepsy?
Do you or any family member suffer from Diabetes?
Bruising or persistent bleeding?
Do you carry a warning card?
Have or had bone or joint disease, arthritis or osteoporosis?
Taking any medications from your Doctor? Tablets, creams, injections etc - Please list if YES
Taken or taking steroids in the last 2 years?
Are you pregnant or recently given birth?
Do you smoke? If so how many weekly?
Do you consume alcohol? If so how many units on a weekly basis?

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