Download health questionnaire

Health Centre Questionnaire
Please complete the details below and bring the form to the
University Health Centre, Marsh Building when you register with a Doctor
Family/ Last Name:
First Name(s):
Address in Preston:
Date of Birth (DD/MM/YY)
Please give further details to the following questions if you answer ‘yes’
Have you ever had any operation(s)? Yes / No
Have you ever had a serious illness? Yes / No
Are you taking any medication? Yes / No
Have you got any allergies? Yes /No
Are you diabetic? YES / NO
Have you been vaccinated against any of the following illnesses?
DATE
Diptheria
Polio
Mumps
Rubella
Smallpox
Hepatitis B
DATE
Tetanus
Whooping Cough
Measles
Tuberculosis
Meningitis C
Any Other
Male And Female
Please read the following information and then tick the box to show that you have
read it.
Condoms are available “free” from the health centre.
Emergency contraception is available from the health centre and must be
taken within 72 hours of unprotected sexual intercourse.
HEIGHT:
WEIGHT:
please circle your answer:
DIET:
EXERCISE:
GOOD
INACTIVE
MODERATE
GENTLE
POOR
MODERATE
SPECIAL DIET
VIGOROUS
SMOKER: YES / NO
How many cigarettes a day do you smoke?
ALCOHOL: YES / NO
How many units a week do you drink?
(1 Pint beer = 2 units 1 glass wine = 1 unit)
The following questions apply to blood relatives including grandparents
(up to age 65 years:)
Family history of Angina/Heart Attack?
Yes / No
Please give details
Family history of High Blood Pressure?
Yes / No
Please give details
Family history of Diabetes?
Yes / No
Please give details
Family history of Cancer?
Yes / No
Please give details
Family history of Tuberculosis?
Yes / No
Please give details
Family history of Stroke?
Please give details
Yes / No