Medical History Questionnaire

226 Burgundy Street
Heidelberg VIC 3084
Ph: 9459 0555
Fax: 9455 0786

Name

Date of Birth

Allergies

Are you allergic to any medications, foods, tapes, lotions, latex?

If yes, what reactions do you have?

Past Health
Do you have or have you ever had?

Heart trouble eg. Heart attack, chest pain, angina, palpitations, irregular heartbeat or heart surgery?

Comments

Insertion of pacemaker, heart valve or stent?

Comments

Rheumatic fever?

Comments

Blood pressure problems?

Comments

Stroke, "mini-strokes", blackouts, migraines, brain surgery?

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Blood clot in lung or leg?

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Anaemia, bleeding tendency or blood disorder? Eg leukaemia

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Breathing problems or lung disease eg asthma, bronchitis, emphysema, sinus, hayfever, T.B or pneumonia?

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Fitting or convulsions/epilepsy or fainting?

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Diabetes

Comments

Thyroid problems? Pancreatitis?

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Kidney or bladder problems? Eg incontinence or infections

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Bowel problems? Eg constipation, haemorrhoids, bleeding inflammatory bowel disease

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Gastric reflux, indigestion, stomach ulcer or hiatus hernia?

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Liver disease eg hepatitis, jaundice?

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Infectious diseases? Eg HIV, hepatitis – what type, TB?

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Arthritis, back or neck problems, spinal surgery, fractures?

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Mobility problems?

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Psychiatric, psychological problems?

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Any other health problems not listed above?

Comments

Do you smoke?

Comments

Do you drink alcohol?

Comments

Medications

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Dose

Frequency

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