Medical Form





    • Attending or receiving treatment from a doctor, hospital or clinic?

    Attending or receiving treatment from a doctor, hospital or clinic?

  • YesNo

  • An expectant or nursing mother?

  • YesNo

  • Taking any medication? e.g. Asprin

  • YesNo

  • Taking any medication for bones?

  • YesNo

  • Receiving blood transfusion services or have you ever had a blood transfusion?

  • YesNo

  • Carrying a medical warning card?

  • YesNo

  • Allergic to medicines, foods, materials? e.g. Penicillin, Latex

  • YesNo

  • Aware of any other illnesses?

  • YesNo

  • Had rheumatic fever?

  • YesNo

  • Had jaundice, liver, kidney disease or hepatitis?

  • YesNo

  • Been told you have a heart murmur, angina, blood pressure, heart attack?

  • YesNo

  • Had a bad reaction to general or local anaesthetics?

  • YesNo

  • Had a joint replacement?

  • YesNo

  • Been Hospitalised? What for and when?

  • YesNo

  • Have arthritis?

  • YesNo

  • Have a pacemaker, artificial valves or have you had any heart surgery?

  • YesNo

  • Have high blood pressure?

  • YesNo

  • Bruise/have prolonged bleeding? e.g. following tooth extraction

  • YesNo

  • Suffer from hayfever, eczema or asthma?

  • YesNo

  • Having fainting attacks, giddiness or epilepsy?

  • YesNo

  • Have diabetes?

  • YesNo

  • Have bronchitis, asthma, COPD?

  • YesNo

  • Smoke cigarettes? If yes, how many/day?

  • YesNo

  • Drink alcohol? If yes, how many units week?
    1 unit – half pint beer / 1 glass of wine

  • YesNo

  • Are you H.I.V positive?

  • YesNo

  • Have you been in contact with someone with COVID-19 in the last 14 days?

  • YesNo

  • Have you had COVID-19?

  • YesNo

  • Do you have COVID-19 at present?

  • YesNo

  • If answered yes to any of the above please give details

  • Iā€™d like to be informed of exclusive offers and other practice informationyes
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