PERSONAL DETAILS

Gender

Purpose of your visit *

MEDICAL HISTORY

SMOKING/ALCOHOL/DRUGS

Smoking Habit? *

Recreational Drug Use? *

Alcohol Consumption? *

CHECKLIST OF PREVIOUS ILLNESS

Blood Pressure - High *

Varicose Veins, Thrombosis of Veins: *

Blood Pressure - Low *

Porphyria (patient or members of family): *

Heart Disorder (Angina, Congenital, Thrombosis, Fever, RH): *

Epilepsy, any other muscular or neurological disorder: *

Diabetes: *

Porphyria (patient or members of family): *

Kidney/Bladder Related: *

Orthopedic Problems: *

Liver Conditions, Jaundice: *

Excess bleeding (post-surgery or injury): *

Ulcers (gastric, duodenal), Diarrhea, Hiatus Hernia: *

Tropical Diseases, Malaria, Etc.: *

Asthma, TB, Bronchitis, Lung Disease: *

Any Recent Minor, illnesses: *