Personal History Information Form

Your Surgery Name Goes Here

All information given on this form will be treated as strictly confidential, as there will be some considerable delay in obtaining your old medical notes, it will be of great help to your Doctor if you would be so kind as to complete this form before attending the Surgery for a simple medical.

Title:
Surname:
Christian Name:
Maiden Name:
Date of Birth:
Address:
Email Address:
Contact Tel. No:

Marital Status:
Religion:
Occupation (please list past and present occupations - in order):



Are you taking any medication or receiving any other treatment at present? If so please list:



ALCOHOL: Units per week: One unit = half pint of beer, small glass of wine, small measure spirit

SMOKING: Please tick	Cigars
	Cigarettes
	Pipe
	Given Up
	Never
Number per day:
Or oz per week:

Do you have any particular allergies to food or drugs or other substances?

Do you have any special handicap?

Is there anything else that would help your doctor to know?

Please list as far as possible your past immunisation dates:








FAMILY HISTORY
Father (if alive) - Age:
Father (if alive) - Any serious illness (see below):
Father (if deceased) - Cause of death:
Father (if deceased) - Age of death:

Mother (if alive) - Age:
Mother (if alive) - Any serious illness (see below):
Mother (if deceased) - Cause of death:
Mother (if deceased) - Age of death:

Brother 1 (if alive) - Age:
Brother 1 (if alive) - Any serious illness (see below):
Brother 1 (if deceased) - Cause of death:
Brother 1 (if deceased) - Age of death:

Brother 2 (if alive) - Age:
Brother 2 (if alive) - Any serious illness (see below):
Brother 2 (if deceased) - Cause of death:
Brother 2 (if deceased) - Age of death:

Brother 3 (if alive) - Age:
Brother 3 (if alive) - Any serious illness (see below):
Brother 3 (if deceased) - Cause of death:
Brother 3 (if deceased) - Age of death:

Sister 1 (if alive) - Age:
Sister 1 (if alive) - Any serious illness (see below):
Sister 1 (if deceased) - Cause of death:
Sister 1 (if deceased) - Age of death:

Sister 2 (if alive) - Age:
Sister 2 (if alive) - Any serious illness (see below):
Sister 2 (if deceased) - Cause of death:
Sister 2 (if deceased) - Age of death:

Sister 3 (if alive) - Age:
Sister 3 (if alive) - Any serious illness (see below):
Sister 3 (if deceased) - Cause of death:
Sister 3 (if deceased) - Age of death:

Children (if alive) - Age:
Children (if alive) - Any serious illness (see below):
Children (if deceased) - Cause of death:
Children (if deceased) - Age of death:

Serious Illness: e.g. Tuberculosis, Diabetes, High Blood Pressure, Heart Attack, Stroke, Asthma, Eczema, Hay Fever, Migraine, Depression, Ulcer, Cancer, Black-outs, Glaucoma, Alcoholism, Nerves, Gout, etc

Please list any past illnesses, accidents or operations. Also include any x rays or other investigations.	List year first, and then illness:

WOMEN
Would you like to register with this practice for contraceptive advice?
Are you fitted with an IUD or Coil?
Are you taking oral contraception?
Have you had a cervical smear test?
Date of last test:

PREGNANCIES AND MISCARRIAGES
Year:
Duration (weeks):
Weight of baby:
Complications: