ADULT CLINICAL INFORMATION - Page 1 of 2 (Please give this sheet to the Doctor or Nurse) As a new patient, completing this form helps us get a detailed overview of your health. This form is confidential and will only be kept in your confidential medical record. Name Date of birth Your current or past health problems (circle any relevant known conditions) ❏ ❏ ❏ ❏ Skin problems Yes No Diabetes/high blood sugar/ Yes No gestational diabetes ❏ ❏ ❏ ❏ Leg ulcers Yes No High blood pressure Yes No ❏ ❏ ❏ ❏ Vision problems/glaucoma Yes No High cholesterol Yes No ❏ ❏ ❏ ❏ Unusual or severe infection/ meningitis Yes No Heart disease/chest pain/ angina/ Yes No rheumatic fever ❏ ❏ ❏ ❏ Teeth/gum problems Yes No Liver disease/jaundice/gallstones Yes No ❏ ❏ ❏ ❏ Asthma/COPD/breathing problems/ Yes No Coeliac disease/malabsorption/ Yes No chronic cough Crohn’s disease/Ulcerative colitis ❏ ❏ ❏ ❏ Bladder/kidney/prostate problems Yes No Stomach ulcers/reflux/indigestion Yes No ❏ ❏ ❏ ❏ Thyroid problem Yes No Hepatitis C/HIV - AIDS Yes No ❏ ❏ ❏ ❏ Anaemia/low blood count Yes No Head injury Yes No ❏ ❏ ❏ ❏ Chronic pain Yes No Sleep apnoea/ sleep disorder Yes No ❏ ❏ ❏ ❏ Unexplained weight loss Yes No Seizures/epilepsy Yes No ❏ ❏ ❏ ❏ Cancer/lymphoma/leukeamia Yes No Anxiety/depression Yes No ❏ ❏ ❏ ❏ DVT/blood clots/bleeding disorder Yes No Other mental health condition Yes No ❏ ❏ ❏ ❏ Arthritis/ Lupus/autoimmune or Yes No Stroke/TIA/other brain or Yes No connective tissue disease neurological problem ❏ ❏ ❏ ❏ Gynaecological problems or breast Yes No Migraine/recurrent or severe Yes No lumps headache ❏ ❏ ❏ ❏ Hearing loss Yes No Blood transfusion Yes No ❏ ❏ Operations/surgery (please list) Yes No Have any family members had any of the following? (continued over page) ❏ ❏ ❏ ❏ High blood pressure or high cholesterol Yes No Stroke Yes No ❏ ❏ ❏ ❏ Heart disease (aged under 65 years) Yes No Diabetes Yes No ❏ ❏ ❏ ❏ Sudden cardiac death (aged under 65) Yes No Bleeding or blood clotting disorder Yes No
ADULT CLINICAL INFORMATION - Page 1 of 2 (Please give this sheet to the Doctor or Nurse) As a new patient, completing this form helps us get a detailed overview of your health. This form is confidential and will only be kept in your confidential medical record. Name Date of birth Your current or past health problems (circle any relevant known conditions) Skin problems Yes ❏ No ❏ Diabetes/high blood sugar/ Yes ❏ No ❏ gestational diabetes Leg ulcers Yes ❏ No ❏ High blood pressure Yes ❏ No ❏ Vision problems/glaucoma Yes ❏ No ❏ High cholesterol Yes ❏ No ❏ Unusual or severe infection/ meningitis Yes ❏ No ❏ Heart disease/chest pain/ angina/ Yes ❏ No ❏ rheumatic fever Teeth/gum problems Yes ❏ No ❏ Liver disease/jaundice/gallstones Yes ❏ No ❏ Asthma/COPD/breathing problems/ Yes ❏ No ❏ Coeliac disease/malabsorption/ Yes ❏ No ❏ chronic cough Crohn’s disease/Ulcerative colitis Bladder/kidney/prostate problems Yes ❏ No ❏ Stomach ulcers/reflux/indigestion Yes ❏ No ❏ Thyroid problem Yes ❏ No ❏ Hepatitis C/HIV - AIDS Yes ❏ No ❏ Anaemia/low blood count Yes ❏ No ❏ Head injury Yes ❏ No ❏ Chronic pain Yes ❏ No ❏ Sleep apnoea/ sleep disorder Yes ❏ No ❏ Unexplained weight loss Yes ❏ No ❏ Seizures/epilepsy Yes ❏ No ❏ Cancer/lymphoma/leukeamia Yes ❏ No ❏ Anxiety/depression Yes ❏ No ❏ DVT/blood clots/bleeding disorder Yes ❏ No ❏ Other mental health condition Yes ❏ No ❏ Arthritis/ Lupus/autoimmune or Yes ❏ No ❏ Stroke/TIA/other brain or Yes ❏ No ❏ connective tissue disease neurological problem Gynaecological problems or breast Yes ❏ No ❏ Migraine/recurrent or severe Yes ❏ No ❏ lumps headache Hearing loss Yes ❏ No ❏ Blood transfusion Yes ❏ No ❏ Operations/surgery (please list) Yes ❏ No ❏ Have any family members had any of the following? (continued over page) High blood pressure or high cholesterol Yes ❏ No ❏ Stroke Yes ❏ No ❏ Heart disease (aged under 65 years) Yes ❏ No ❏ Diabetes Yes ❏ No ❏ Sudden cardiac death (aged under 65) Yes ❏ No ❏ Bleeding or blood clotting disorder Yes ❏ No ❏
PMC-Adult-Medical-History-Form.docx