CONFIDENTIAL MEDICAL
HISTORY QUESTIONNAIRE
Please complete the on-line form below ahead of your appointment.
Or download the form and complete.
The contents of this questionnaire are confidential and will be used as part of your medical record.
The contents will not be shared outside of the Nuffield Heath Hospital.
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Title:
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Thank You!
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Surname:
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Forename:
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Date of Birth:
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Contact Tel No:
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Email:
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SECTION 2: Personal History
SECTION 1: Personal Details
Please provide details of any significant current / past history, e.g operations, serious illness etc …
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Do you have any allergies? (please specify)
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Asthma (If yes, please give details)
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Do you have any of the following conditions (if yes, how long have you had the condition)
High blood pressure (If yes, please give details)
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Epilepsy (If yes, please give details)
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Diabetes (If yes, please give details)
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Heart condition (If yes, please give details)
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Liver condition (If yes, please give details)
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Lung condition (If yes, please give details)
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Depression/anxiety (If yes, please give details)
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Psychiatric condition (If yes, please give details)
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Diabetes (If yes, please give details)
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Is there a family history of:
Heart condition (If yes, please give details)
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High blood pressure (If yes, please give details)
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Do you smoke? (If yes, how many cigarettes per day and for how long)
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Do you drink alcohol? (If yes, how often / quantity)
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Please list any current medications you are currently taking
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Please select which hospital you are attending:
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