New Patient Medical History Form New Patient Medical History Form First Name*Last Name*Date of Birth*Do you intend to use us as your regular GP?* Yes No Undecided Are you currently taking any medication?*Are you currently undergoing any medical treatment or any operations recently?*Do You Smoke?* Yes No How many cigarettes per day?Alcohol Usage* Never Occasional Heavy How many drinks per weekDo you have any allergies to medication or materials (e.g. penicillin or latex)* Yes No Please explainFemale Patients - please advise date of last pap smear Was your Pap Smear Results Normal or Abnormal?* Normal Abnormal Are you Pregnant? No Yes Due Date Please select any conditions that apply. High/Low Blood Pressure Epilepsy Heart Surgery/Attack Rheumatic Fever Diabetes Type 1 Diabetes Type 2 Heart Complaint Allergies or Hives Hepatitis A, B, C Asthma or Breathing Problems Arthritis or Back Pain Anaemia Steroid Therapy Stroke Contact with HIV/AIDS Kidney Disease Emphysema Stomach Ulcers Tuberculosis Bleeding Disorder Thyroid Disease Sinus Therapy Depression or Mental Illness Diarrhoea or bowel trouble Indigestion or reflux Artificial Joint LIver Disease Cancer Please comment below if there is any family history of Diabetes, Heart Disease, Tumours etc. By submitting this New Patient Medical History Form you agree that all information is correct and accurate to the best of your knowledge.