Medical History Form

Name*

Prefix First Last

Occupation*

Age*

Date of Birth*

DD

MM

YYYY

Email*

Phone*

COVID

Have you had COVID vaccinations?*

No
Yes - First Vaccination
Yes - Second Vaccination
Yes - Booster (Third) Vaccination

Have you had COVID?*

Yes
No

Date

DD

MM

YYYY

Weight/Medical History

Height*

Current Weight*

Is this your heaviest weight?*

Yes
No

What is your heaviest weight?

Do you have any known drug or dressing allergies?*

Yes
No

Please list all allergies, including drugs or dressings

Previous Surgeries (please write none if no surgeries)*

Have you ever had a blood clot?*

Yes
No

Details

Do you take any regular ‘blood thinning’ medications?*

Other Medications

Do you take any other regular medications? (please list)

Alcohol

How many standard glasses of alcohol do you drink?

Average Per week:*

Smoking

Do you smoke?*

Yes
No

How many per day?

Previous smoker?*

Yes
No

How many per day?

Year ceased?

Do you or have you suffered with any of the following health problems:

Diabetes*

Yes
No

Details

Gestational Diabetes (Diabetes while pregnant)*

Yes
No

Details

Asthma*

Yes
No

Details

Respiratory/Breathing/Sleep Apnoea*

Yes
No

Details

Arthritis*

Yes
No

Details

High Blood Pressure*

Yes
No

Details

Heart Disease*

Yes
No

Details

High Cholesterol*

Yes
No

Details

Heartburn or Gastroesophageal Reflux*

Yes
No

Details

Depression/Anxiety*

Yes
No

Details

Comments

This field is for validation purposes and should be left unchanged.

Helping you achieve a healthier lifestyle.

Contact Form:

COVID

Weight/Medical History

Alcohol

Smoking

Do you or have you suffered with any of the following health problems:

Dr Ian Martin Surgery

Scheduling an appointment is an important first step towards a sustainable, healthier and brighter future.