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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