Health Summary Page 2
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3Previous General Practitioner:
Address:
Last seen on:
Phone:
Allergies (if any):
Do you drink alcohol now?
YES / NO
(please circle)
If so, how many days a week do you drink?
1–2 days
3-4 days
5-6 days
Every day Less than Monthly
How many drinks per day
If not, have you ever been a drinker? (if so when):
Do you smoke?
YES / NO
(please circle)
If so, how many do you smoke per day:
If not, have you ever been a smoker? (if so when):
Past Medical History:
Have you had any operations? Please list type & approximate date:
Do you have any of the following conditions / diseases
(please tick all that apply) :
Asthma
Hepatitis
Anxiety
Emphysema
Peptic ulcer
Depression
Tuberculosis
Arthritis
Schizophrenia
Heart disease
Gout
Anaemia
Stroke
Osteoporosis
Abnormal pap smear
High blood pressure
Dermatitis/Eczema
Cancer of any type
High cholesterol
Psoriasis
Diabetes
Eye condition
Dementia
Any other conditions:
Coeliac disease
Migraines
Blood clots
Seizures or fits
Immunisations:
Up to date with childhood immunisations:
YES / NO
(where applicable)
(please circle)
Travel vaccines received:
Current Medications
Prescriptions:
Over the counter :
Herbal :
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