Patient Health Information Form

Here is a copy of our Medical Background form which we invite you to fill in on your arrival, the first time you see Dr Terren.  If you would like to print and fill one in before you come, there is a link to a pdf version down the bottom of this page, which you can click and then print.

 

CONFIDENTIAL MEDICAL BACKGROUND

 

Name__________________________________ Age____________ Today’s date _______________

 

I would be grateful if you could complete this form which includes some background medical health information.  It will help me to consider other factors which may be relevant to your current health problems.

 

Have you had any of the following?

 

Allergies or reactions to any medications………….          Yes ?…No ?……………………..…

Asthma or other breathing problems       ………….          Yes ?…No ?……………..…………

High blood pressure  ………………………………..           Yes ?…No ? ……………….………

Heart problems or chest pains  …………………….          Yes ?…No ?………………..………

Urinary problems of any sort……………………….           Yes ?…No ?…………..……………

Bowel problems of any sort  ……………………….           Yes ?…No ?………………………

Diabetes …………………………………………….…          Yes ?…No ?………………………

Stroke  …………………………………………………           Yes ?…No ?………………………

Fits, funny turns or collapse…………………………          Yes ?…No ?………………………

Problems with “nerves”, depression   ………………          Yes ?…No ?………………………

Duodenal ulcers or hiatus hernia  ………………….           Yes ?…No ?………………………

Do you smoke?…………………………………………….       Yes ?…No ?………………………

Have you ever smoked regularly in the past?……..          Yes ?…No ?………………………

Have you had a cholesterol test?  (result……)……          Yes ?…No ?………………………

Any blood tests in the last 3 months  ………………         Yes ?…No ?………………………

Any x-rays or other tests in the last 3 months  ……         Yes ?…No ?………………………

 

Previous operations ________________________________________________________________________

_________________________________________________________________________________________

Previous illnesses or hospitalizations ___________________________________________________

Other General Practitioners or Specialists you have seen recently ____________________________

Major illnesses that your parents have or had ____________________________________________

List all current medications, including dose and number of times daily _________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

 

If you would like to print out this form and bring it along, filled in, click on this link:

CONFIDENTIAL MEDICAL BACKGROUND