Patient Name (required)

Contact Phone number

Home Postcode

Are you receiving any treatment from a doctor/specialist/hospital/clinic?
---YesNo

Are you taking any prescribed medication (Such as tablets, creams, inhalers, injections, contraceptives or HRT, if so please type them below?
---YesNo

Medication List

Do you or anyone in your immediate family have diabetes?
---YesNo

Are you allergic to any medicines or materials, if so please type them below?
---YesNo

Allergy List

Do you have a Medical Warning Card, if so please bring it to your appointment
---YesNo

Do you have angina or high/low blood pressure?
---YesNo

Do you have bronchitis, asthma, or any other chest condition?
---YesNo

Do you bruise easily or bleed excessively?
---YesNo

Do you have fainting attacks, giddiness, blackouts, or epilepsy?
---YesNo

Do you smoke or use tobacco products (such as paan or gutkha)?
---YesNo

Have you ever used tobacco products in the past?
---YesNo

Do you drink alcohol?
---YesNo

Do you/the patient have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
---YesNo

Have you ever had rheumatic fever?
---YesNo

Have you ever had a heart attack?
---YesNo

Have you ever had heart surgery or a pacemaker fitted?
---YesNo

Have you ever had a stroke?
---YesNo

Have you ever had jaundice, liver, kidney disease, or hepatitis?
---YesNo

Have you ever had a joint replacement or other implants?
---YesNo

Have you ever had a bad reaction to general or local anesthetic?
---YesNo

Have you taken steroids in the last two years?
---YesNo

Ladies Only, Are you pregnant?
---YesNo

Declaration: I confirm that to the best of my knowledge, the information I have provided on this form is accurate and complete.

Please type your name below to confirm.

Name