Health Summary Page 3
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3Activity
What form of activity do you do each week? eg. walking, golf, gardening. How many days per week do you do each?
Do you ever experience any of the following during or after exercise? Breathlessness
Cough
Wheeze
Chest pain
Dizziness
(please circle)
Family History
Do you have a family history (including parents/siblings/extended family) of any of the following:
(circle all that apply)
High blood pressure
High cholesterol
Heart disease
Stroke
Cancer
Eye condition
Diabetes
Blood disorder
Asthma
Eczema
Any other conditions:
Women’s Health
(as appropriate)
When was your last pap smear?
Was it:
Normal
Abnormal
Not sure
(please circle)
When was your last mammogram?
Is there a family history of breast cancer?
Mother
Sister
Other relative
(please circle)
Are you pregnant currently?
YES / NO
(please circle)
Men’s Health
(as appropriate)
When was the last time you had a prostate examination?
Never
Can’t Remember
_________Years ago
Reminder Systems:
Our practice provides our patients with preventive care and early case detection reminders:
e.g. immunisations, annual health checks, skin checks and pap smears.
I agree to have any relevant health reminders sent to me. I agree to receive SMS contact/reminders from the surgery.
Who completed this form?:
SELF / OTHER
(please circle)
If other, name, phone no. and relationship to patient:
Signature: ________________________________
Date:____________________
Page 3 of 3
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