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Patient Questionnaire and Medical Information Sheet

Please complete the form below. Alternatively, you can download a PDF version here.

1Introduction

2Current Medications

3Medical History

4Surgical History

5Family History

INTRODUCTION......

This information sheet is intended to help gather information about your medical history, to assist the consultation. Any responses that you are not able to complete, for whatever reason (e.g., uncertainty, not enough space provided, confidentiality) can be discussed during the consultation.
GENERAL INFORMATION...
Full Name
Date of Birth
Place of Birth
Marital Status
- Married / Defacto
- Single
- Widowed
- Separated / Divorced
Next of Kin
Dependants / Children
Referring Doctor
MAIN CONCERN / REASON for CONSULTATION...
Reason
ALLERGIES...
Do you have any allergies?
- No
- Yes
1. Allergic to:
1. What happens?
2. Allergic to:
2. What happens?
3. Allergic to:
3. What happens?
WEIGHT...
Current weight

kg
Ideal weight

kg

CURRENT MEDICATIONS...
Are your currently on any medication?
- No
- Yes
If yes, please detail below
1. Medical Condition
1. Drug & Dose
1. Frequency
2. Medical Condition
2. Drug & Dose
2. Frequency
3. Medical Condition
3. Drug & Dose
3. Frequency
Do you regularly take any over the counter medicines, vitamins, complimentary or herbal medicines?
- No
- Yes
If yes, please detail below
Details
SMOKER...
Do you or have you ever smoked?
- Never
- Yes
- Previously - stopped
How much do / did you smoke?

___ per day for ___ years
ALCOHOL INTAKE...
Alcohol Intake
- Never
- Yes
- Previously - stopped
How much do / did you drink?

___ per day for ___ years
DIET...

Have you ever been diagnosed with...
Iron deficiency
- Yes
- No
Year
Vitamin B12 deficiency (pernicious anaemia)
- Yes
- No
Year
Coeliac disease
- Yes
- No
Year
Vitamin D deficiency
- Yes
- No
Year
Does your diet include the following...
Dairy
- Milk
- Yogurt
- Cheese
Cereals
- Grains
- Bread
- Breakfast Cereals
Meat
- Red Meat
- Chicken
- Fish
Vegetables
- Potato
- Green Leafy Vegetables
Fruit
- Yes
FOOD ALLERGIES...
Do you have any food allergies
- Yes
- No

Have you been hospitalised during the past year?
- Yes
- No
If yes, please detail below
Have you been treated or hospitalised for any of the following:
Asthma
- Yes
- No
Asthma - Comments
Eczema
- Yes
- No
Eczema - Comments
Rash
- Yes
- No
Rash - Comments
Chest Infections
- Yes
- No
Chest Infections - Comments
Recent Infections
- Yes
- No
Recent Infections - Comments
Migraine / Severe Headache
- Yes
- No
Migraine / Severe Headache - Comments
Seizures / Epilepsy
- Yes
- No
Seizures / Epilepsy - Comments
Diabetes
- Yes
- No
Diabetes - Comments

Year: YYYY | Insulin Injections: Y/N | Tablets: Y/N
Urinary Tract Infection
- Yes
- No
Urinary Tract Infection - Comments
Diverticulitis Infections
- Yes
- No
Diverticulitis - Comments
Heart Problems
- Yes
- No
Heart Problems - Comments
High Blood Pressure
- Yes
- No
High Blood Pressure - Comments
Arrhythmia / Abnormal Heart Beat
- Yes
- No
Arrhythmia / Abnormal Heart Beat - Comments
Heart Attack / Myocardial Infarction
- Yes
- No
Heart Attack / Myocardial Infarction - Comments
Angina
- Yes
- No
Angina - Comments
Bleeding / Bruising
- Yes
- No
Bleeding / Bruising - Comments
Deep Venous Thrombosis (clot)
- Yes
- No
Deep Venous Thrombosis (clot) - Comments

Site: | Warfarin: N/Y
Pulmonary Embolism (lung clot)
- Yes
- No
Pulmonary Embolism (lung clot) - Comments

Details
Shingles / Chicken Pox
- Yes
- No
Shingles / Chicken Pox - Comments
Cold Sores / Whitlow
- Yes
- No
Cold Sores / Whitlow - Comments
Hepatitis
- Yes
- No
Hepatitis - Comments
Learning Difficulty
- Yes
- No
Learning Difficulty - Comments
Physical Disability
- Yes
- No
Physical Disability - Comments
Depression
- Yes
- No
Depression - Comments
Other Emotional Concerns
- Yes
- No
Other Emotional Concerns - Comments
Other (Details?)

Surgical History
Year
Reason
Year
Reason
Year
Reason
Year
Reason
Have you ever had...
Joint Replacement
- Yes
- No
Joint Replacement - Details
Broken Bone
- Yes
- No
Broken Bone - Details
Major Head Injury
- Yes
- No
Major Head Injury - Details
Dental Extraction
- Yes
- No
Dental Extraction - Details
When was your last dental examination?
Do you wear dentures
- Yes
- No
Dentures - Details
Immunisation...
Have you been immunised for the following?
Influenza (this year)
- No
- Yes
- Unsure
- Previous years eg since
Previous years eg since
Whooping cough (Pertussis)
- No
- Yes
- Unsure
- Grandparents
Pneumococcus (Pneumovax)
- No
- Yes
- Unsure
- >65yrs, no spleen
Haemophilus (Hib)
- No
- Yes
- Unsure
- Lung disease, low immunity
Chickenpox / Varicella (Zostervax)
- No
- Yes
- Unsure
- Recurrent shingles >50yrs
Hepatitis B and/or A
- No
- Yes
- Unsure
Papilloma Virus HPV (Gardisil)
- No
- Yes
- Unsure
Diphtheria/Pertussis/Tetanus
- No
- Yes
- Unsure
Measles, Mumps, Rubella (MMR)
- No
- Yes
- Unsure
Meningococcal
- No
- Yes
- Unsure
Tuberculosis (BCG)
- No
- Yes
- Unsure
Other (eg travel)

Family History...
Mother
Status
- Alive
- Died
Died at ___ years
Father
Status
- Alive
- Died
Died at ___ years
Children
years
Children
years
Children
years
Brothers / Sisters
years
Brothers / Sisters
years
Is there any family history of
- leukaemia
- lymphoma
- bleeding
- thrombosis
- cancer
Other relevant information about family members / illnesses
COMPLETED BY...
Thank-you for your time. When you have your consultation, please let me know if you have any questions about this form.
Name
First Last
Signature
Date
MM slash DD slash YYYY

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