Download New Patient Medical Questionnaire

New Patient Medical Questionnaire
All information is strictly confidential
Please give this form directly to your doctor at your initial consultation
SURNAME: ____________________________ GIVEN NAMES:___________________________
DATE OF BIRTH:__________________ Height: _________________ Weight:____________________
Do you have any allergies?
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Please list current medications including vitamins and mineral supplements:
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Please list any medical history and past surgery/operations /previous illnesses/injuries:
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Have you recently been in hospital? If so, please provide details:
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Have you ever had, or is there family history of:
 Diabetes
 Asthma
 Heart disease
 Cancer
 Stroke
 Other: _____________________________________________________
Please provide details:
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LIFESTYLE HEALTH HISTORY
Smoking history:
 Never smoked
 Former smoker – quit date :
 Current smoker -.............. /day
Number of years smoking: _______
Alcohol history:
Do you drink alcohol? :
 Yes
Number of standard drinks/day:________
 Never
WOMEN’S HEALTH:
MEN’S HEALTH:
Date of last Pap smear: ___________
Date of last prostate check _______
(if over 40)
Date of last mammogram (if over 40) _________
IMMUNISATIONS (please tick relevant boxes)
 Pneumococcal (pneumonia)
 Childhood vaccines up to date
 Influenza
 Tetanus
 other (please specify) ____________________________
Is there anything else that may be relevant to your medical history?
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Patient signature:
Date: