Medical History Form

Part 1

Please complete both parts and do let us know if any of your circumstances change between appointments.

We are happy to help you to complete this form, should you experience any problems in completing it.

Are you:

Currently receiving treatment from a doctor, hospital or clinic *

Taking any prescribed medicines(tablets, ointments or inhalers including contraceptive and hormone replacement therapy)*

Carrying a medical warning card*

Diabetic*

Do you suffer from:

Arthritis or Osteoporosis*

Bruising or persistent bleeding following injury/dental extractions/ surgery*

Infectious diseases including Hepatitis/ HIV*

Allergies to any medicine e.g. penicillin, substances e.g. latex or foods*

Hay fever, eczema*

Bronchitis, asthma or chest conditions*

Fainting attacks, giddiness, blackouts, epilepsy*

Heart problems, angina, blood pressure problems, stroke*

Have you ever had:

Rheumatic fever or chorea *

Liver disease, jaundice, hepatitis, kidney disease*

Any other serious illness*

Blood refused by Blood Transfusion Service*

Adverse reaction to general or local anesthetic*

Joint replacement or implant*

Heart surgery*

Brain surgery*

Did/Do You:

Receive growth hormone treatment before the mid 80’s*

Have any close relatives with Creutzfeldt Jakob disease*

Regularly drink more than 21 units of alcohol per week*

Smoke tobacco products or have done so*

Had any treatment with hydro-cortisone/ corticosteroids in the past 2 years*

Any other medical or other information we should be aware of e.g. self-prescribed medicines*

Are you pregnant?*

Part 2

Your Covid Risk Category

Please indicate any of the following which apply to you:

Frontline health worker or carer or confirmed case of covid in your own household *

Keyworker in contact with public, but has had no symptoms and no known exposure to person with symptoms*

Minimum public contact and isolating at home or with family members, no known exposure to covid 19*

Has had covid and recovered and this was confirmed by testing and documentation*

Has underlying health issue and is in a vulnerable category*

Someone in household tested positive*

Is anyone isolating in your household?*

Has anyone in your household been experiencing symptoms?*

Do you have:

Persistent cough *

Shortness of breath/ difficulty breathing/ change in breathing*

Raised temperature - over 37.8C/100F*

Unexplained tiredness / lethargy*

Loss of taste or smell*

Muscular aching, that is new to you*

Stomach upset, including diarrhoea, that is new to you*

Are you aged over 70?*

Entries marked with * are required.

We'll only store and process your details for the purposes related to this form and we will not sell or share them with any third parties.

Your details will be kept for five years before the records are removed. You can ask to see what details we hold about you and request that they be removed at any time by contacting the us in writing.


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