medical history form

Medical History

  • Please fill in this information as fully as possible as it will help accurate diagnosis and lead to a better treatment.

  • MM slash DD slash YYYY
  • Illnesses: Please list any surgery, accidents, or reasons for other hospital/regular GP visits, and note approximate age. Also make a note of any scars from accidents or operations.

  • Please list any major illnesses in your immediate family (parents, siblings and grandparents) e.g cancer, diabetes, heart disease, blood pressure, blood disorders, neurological problems, psychological problems etc

  • Please tick any symptoms you have now. Please underline problems which you have been affected by in the past.

  • Skin

  • Gastro-intestinal

  • Respiratory

  • Hormonal

  • Gender Specific

  • Autoimmune

  • Focal infections

  • Tissue or ligaments

  • ENT

  • Oral disease:

  • General Symptoms

  • Medication & Drugs