Medical details If you are taking prescribed medication, please make an appointment to see your doctor within two weeks and bring your medicines with you. (We will not be able to issue any repeat prescriptions until you have seen a doctor.) *Are you allergic to any medicines? Yes No (if yes please specify) *List other allergies / intolerances (i.e. nuts, gluten, pollen, animal hair or certain foods. Please if you have no other allergies that you know of) mark “none” Have you ever had any of the following conditions? Epilepsy Yes Year Mental Illness Yes Year High Blood Yes Year Diabetes Yes Year Pressure Yes Year Yes Year Heart Asthma Attack / Angina Stroke / Yes Year COPD (or Yes Year Mini-stroke Emphysema) (TIA) Cancer Yes Year Osteoporosis / Yes Year Bone fractures Rheumatoid Yes Year Peripheral Yes Year Arthritis vascular disease Do you have any of the following? Coil Yes Date of procedure 615p Implant Yes Date of procedure 61KA Pessary Yes Date of procedure 7D1B6 Pacemaker Yes Date of procedure ZV450
Medical details If you are taking prescribed medication, please make an appointment to see your doctor within two weeks and bring your medicines with you. (We will not be able to issue any repeat prescriptions until you have seen a doctor.) *Are you allergic to any medicines? Yes No (if yes please specify) *List other allergies / intolerances (i.e. nuts, gluten, pollen, animal hair or certain foods. Please mark “none” if you have no other allergies that you know of) Have you ever had any of the following conditions? Epilepsy Yes Year Mental Illness Yes Year High Blood Pressure Yes Year Diabetes Yes Year Heart Attack / Angina Yes Year Asthma Yes Year Stroke / Mini-stroke (TIA) Yes Year COPD (or Emphysema) Yes Year Cancer Yes Year Osteoporosis / Bone fractures Yes Year Rheumatoid Arthritis Yes Year Peripheral vascular disease Yes Year Do you have any of the following? Coil Yes Date of procedure 615p Implant Yes Date of procedure 61KA Pessary Yes Date of procedure 7D1B6 Pacemaker Yes Date of procedure ZV450
Adult%20New%20Patient%20Questionnaire.docx