New Patient Medical History Form

Do you intend to use us as your regular GP?

YesNoUndecided


Do You Smoke?*

YesNo

Alcohol Usage

NeverOcassioanlyHeavy

Female Patients - please advise date of last pap smear

Was your Pap Smear Results Normal or Abnormal?*

NormalAbnormalHeavy

Are you Pregnant?

YesNo

Please select any conditions that apply.

High/Low Blood PressureDiabetes Type 1Hepatitis A, B, CSteroid TherapyEmphysemaThyroid DiseaseIndigestion or refluxEpilepsyDiabetes Type 2Asthma or Breathing ProblemsStrokeStomach UlcersSinus TherapyArtificial JointHeart Surgery/AttackHeart ComplaintArthritis or Back PainContact with HIV/AIDSTuberculosisDepression or Mental IllnessLIver DiseaseRheumatic FeverAllergies or HivesAnaemiaKidney DiseaseBleeding DisorderDiarrhoea or bowel troubleCancer

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.