Medical Details

Details

Name

Medical Details/History

Have you had a previous diagnosis of cancer?

If yes, specify

Do you have heart issues?

If yes, please check:
NoneAnginaHeart attackIrregular pulseFaintingMurmurEndocarditisRheumatic feverPacemaker

Do you have lung or breathing problems?

If yes, specify

Have you had any neurological problems? (eg. Stroke or seizure)

If yes, please explain

Do you have diabetes?

If yes, which type of current treatment:
NoneDiet onlyTabletsInsulinPump

Do you have high blood pressure?

Have you ever had any blood clots in your legs or lungs?

Do you have any autoimmune illnesses?

If yes, specify

Do you have a blood or bleeding disorder?

If yes, Please explain

Are you, or could you be pregnant?

If yes, how many weeks

Are you currently breastfeeding?

Have you had any of the following:
Hepatitis BHepatitis CHIV

Other medical conditions we should be aware of?

Do you smoke or have you ever smoked?

If yes, specify (approximately):

Number per day

Number of years

Age started

Age stopped

Do you drink alcohol?

If yes, how much and how often?

Have been exposed to hazardous substances? (eg. asbestos, benzene etc.)

If yes, specify

Your mobility:

Medications

Do you take any regular medication? (including herbal, or over the counter medications)

Current Medications & Daily dose

Allergies

Do you have any allergies or sensitivities to any medications, latex, food or other:

Medication/Substance & Type of Reaction

Family History

Do you have any family history of cancer?

If yes, specify

Maternal (Mother’s side)

Paternal (Father’s side)

Other

Past Surgery

Enter any previous operations you have had:

Operation type & When