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Medical History Form

Form 3

Please Write Clearly

For Office Use Only DD MM YY
CHI Number 

Please tick the appropriate box. If you have further details, including any allergies or pills, tablets
or other Medication that you take, please enter them in the ‘Further Details’ box.

Are you aware of anything that you are allergic to? (penicillin or another antibiotic, pollen, latex, food, jewellery or any other substance)

Checkbox 1 *

Have you ever had any heart problems/conditions? (blood pressure problems, angina or chest pains, pacemaker or any other heart or blood vessel condition)

Checkbox 2 *

Have you ever had any chest or breathing problems/conditions? (asthma, bronchitis or any other breathing problems)

Checkbox 3 *

Have you ever had any stomach, gut, liver or kidney problems/conditions?

Checkbox 4 *

Do you have any blood or bleeding problems/conditions?

Checkbox 5 *

Are you prone to fts/faints or do you have epilepsy?

Checkbox 6 *

Do you have any problems or conditions relating to your bones, joints or muscles? (arthritis, muscle weakness or any other condition)

Checkbox 7 *

Do you have hepatitis, HIV, AIDS or tuberculosis (TB)?

Checkbox 8 *

Are you pregnant, or is there a possibility you could be pregnant?

Checkbox 9 *

Do you have diabetes?

Checkbox 10 *

Do you have a medical condition or problem not specifed above?

Checkbox 11 *

Are you currently under treatment from a doctor, consultant or clinic?

Checkbox 12 *

Do you carry a medical warning card?

Checkbox 13 *

Are you taking or meant to take medicine prescribed by your doctor or otherwise? (tablets, pills, patches, medicines, inhalers, ointments, injections, oral contraceptives, herbal remedies, recreational drugs, recent vaccinations). If yes, please enter them in the ‘Further Details’ box below.

Checkbox 14 *

Are there any conditions that run in your family? (diabetes, sickle cell disease or any other conditions). If yes, please enter them in the ‘Further Details’ box below.

Checkbox 15 *

Have you ever had an illness or operation that required hospital treatment? If yes, please enter them in the ‘Further Details’ box below.

Checkbox 16 *

Additional Requirements or Special Needs (Please tick appropriate box or boxes)

Additional Requirements *
Armed Forces *

Further Details including any allergies or pills, tablets or other medication that you take