We ask you for your information about your general health to help us treat you safely. Please write your contact details below, answer the health questions and then submit the form. We will use this form at later visits to discuss any change in your general health. All information will be kept strictly confidential by the people caring for you.

Personal Information


Contact details

In the Event of an emergency please contact

Doctor's details

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Have you ever had...

Blood refused by the Blood Transfusion service or any other agency abroad?

A bad reaction to general or local anaesthetic?

A joint replacement or implant?

Treatment that required you to be in hospital?

Heart surgery or a stent?

Brain surgery?

Are you pregnant or possibly pregnant?

Any form of mental illness (eg depression, anxiety, stress, eating disorders)?

Have you been diagnosed with dementia?



Do you smoke or chew any tobacco-products (or did you in the past)?

Do you vape/use electronic cigarettes (or did you in the past)?

Are you currently?

Receiveing treatment from a doctor, hospital or clinic?

Taking or previously taken Biphosphonates (oral or IV) eg alendronic acid, prolia?

Taking any other prescribed medicines, other tablets, ointments, injections or inhalers including contraceptives and hormone replacement therapy?

Carrying a medical warning card?

Have you ever had

Allergies to medicines (eg Penicillin), or substances (eg latex/rubber) or foods?

Do you suffer from hay fever or eczema?

Bronchitis, asthma or other chest conditions?

Fainting attacks, giddiness, blackouts or epilepsy?

Heart problems, angina, blood pressure problems or stroke?

Diabetes (or is there anyone with diabetes in your family)?

Bone or joint disease?

Bruising or persistent bleeding following injury, tooth extraction or surgery?

An infectious disease (including HIV and Hepatitis)?

Rheumatic fever or Cholera?

Liver disease?

Any other serious illness?

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Have an emergency?

Check out our common problems and emergency guide

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