Medical History Form

First Name

Last Name

Date of Birth

Allergies

Medication/substance

Reaction

Severity

Medication/Substance

Reaction

Severity

Medications

Please list regular medications

Medical History

Please list current conditions

Please list past medical history e.g. surgery, significant medical events

Immunisation History

Please list immunisation including dates

Preventative Health

Have you ever had...

Skin Check

Date

National Bowel Screening (if over 50 years)?

Date

Cervical Screening Test (Pap Smear)

Date

Breast Check

Date

Family History

Diabetes

Heart Disease

Kidney Disease

Asthma

Cancer

Other

Please specify

Lifestyle Factors

Alcohol

Smoking

Smoking History

Never smokedSmokerEx-smoker

What type of substance do you smoke?

CigarettesCigarsMarijuana Other

Number of smokes per day

Number of years smoking

Exercise

Nutrition

How often do you eat fruit & vegetables

Every dayA couple of times a weekRarely or never

Comments

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