Medical History Form
AND TITLE ..D.O.B
Town/suburb of residence . ..
Contact in case of emergency Phone
Name of regular doctor (if applicable) ..Phone .
Do you have an allergy to any drugs, foods, or medications (especially penicillin)? Yes No
Do you take any regular medications (including puffers and oral contraceptives)? Yes No
Have you now or in the past had any of the following ailments?
Cardiovascular problems (heart complaint, murmur, angina, high blood pressure etc) Yes No
Respiratory problems (chest or breathing problems, for example asthma) Yes No
Stomach or bowel problems (gastric reflux etc) Yes No
Are you or might you be pregnant or breast-feeding? Yes No
Have you ever been in a high risk group for AIDS (ie. homosexual, bisexual,
user of intravenous drugs, sexual partner or child of any of the above)? Yes No
Have you ever been exposed to Creutzfeld-Jacob disease? Yes No
PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS YOU HAVE EVER HAD
Hepatitis Diabetes Epilepsy Rheumatic Fever Kidney Disease
Bleeding disorder Anaemia Tuberculosis Thyroid disease
Psychological condition Prosthetic appliance Stroke Any other condition
I have completed this form to the best of my knowledge and acknowledge that this represents an accurate medical history. On future visits I will advise of any changes to the history.
Signed ..Date .
(Parent/Guardian if under 18 years)