Forms

Medical History

Name*

Email Address*

Phone:

Do you have any of the following conditions?

Allergies

Anaemia

Arthritis

Asthma

Bleeding Disorder

Cancer

Diabetes

Gallbladder Problem

Glaucoma

Heart Disease

Heart Murmur

High Blood Pressure

Do you have any of the following conditions?

Kidney Conditions

Liver Problems

Lung Conditions

Prostate Problems

Rheumatic Fever

Sinus Infection

Seizures

Stroke

Stomach Problems

Thyroid Condition

Tuberculosis (TB)

Other (complete below if yes)

List of Other Serious Problems:

Do you have any allergies to drugs, food, antibiotics, dyes, or local anaesthetics?

Yes

No

If yes, please list:

Has your weight changed in the past year?

Yes

No

Please list all your current medicines and remedies you take, including dose.

Do you take any blood-thinning medication?