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Medical Questionnaire

Please complete our online medical history form below to allow your doctor to accurately treat you. If there are any sections you prefer not to answer please feel free to leave them blank. Alternatively you can download a pdf version here, fill it offline and hand it to your doctor at your consultation.

    CURRENT MEDICAL CONDITIONS

    Have you suffered from any or currently have any of the following?

    CURRENT MEDICATIONS

    Please list any tablets/injections that you are currently taking alongwith the dose if known. Please include the contraceptive pill and any vitamins or “natural remedies” that you may be on.

    ALLERGIES

    Do you have any allergies? If so please list the allergies, type of reaction that you have and any medication that is taken for them.

    PAST MEDICAL HISTORY

    Please list any serious illnesses, operations, hospital admissions that you have had or currently have

    PAPSMEAR/MAMMOGRAM

    VACCINATIONS

    Please indicate if you have ever had any of the following vaccinations.

    LIFESTYLE

    FAMILY HISTORY

    Has anyone in your close family suffered from the following conditions?

    Disease

    FINALLY