Health Questionnaire

First Name

Surname

Date of Birth

Please list all medications you are currently taking.

Please name your preferred pharmacy

Alcohol Guidelines

^{*one standard drink of alcohol = 100 ml wine (12.5%) one 330ml can of beer (4%) or one 30ml shot of spirit}

Do you have any allergies (e.g. medications, food, latex, pollen)?

Yes

If yes please list:

Please list any significant illnesses/operations/diagnoses you have had/currently have (including month and year if known):

Disabilities: Please describe any disabilities you have:

Have you had a tetanus vaccination?

Yes

If Yes, when was you last tetanus vaccine (month and or year if known)?

Have you had a COVID vaccination?

Yes

What is your height?

What is your weight?

Do you require an interpreter service for your medical appointments?

Yes

If yes, which language?

Do you have a family history of:

Diabetes

Yes

If yes, what relation and how old were they at the onset?

Heart Disease

Yes

If yes, what relation and how old were they at the onset?

Stroke

Yes

If yes, what relation and how old were they at the onset?

Cancer

Yes

If yes, what relation, what type of cancer and how old were that at the onset?set?

Please list any any other relevant family history, include which relation and how old they were at the onset.

Is there any other personal or family history you wish to share with us?