PRE-CONSULTATION QUESTIONAIRE

FIRST NAME:


SURNAME:


D.O.B.:
(ie dd/mm/yyyy)
ADDRESS:


SEX:
Male
Female

WEIGHT
OCCUPATION:

Single
Married
Divorced

CHILDREN:

CONTACT No:

PRESENT GP:

APPOINTMENT:
Very urgent
(within 24hrs)
Urgent
(2-3 days)
Soon
(4-5 days)


PRESENT COMPLAINT
(A brief account. Give the time your
symptoms are at their worse)


PREVIOUS DRUG HISTORY
(Please note; prescription drugs can cause diseases,
and their side-effects can also mimic any disease)



Are you on regular medication ?
If YES, please list any prescription drugs, any over-the-counter drugs,
and any recreational drugs.
YOU MUST HELP US TO HELP YOU!

CLINICAL HISTORY
(A brief account and its important to try and recall your original symptoms and feelings as to why you visited your GP in the first place -
before you even started any course of drugs)
MEDICAL HISTORY
(List any major accidents, operations,
illnesses and traumatic events that may have happened to you)
ALLERGIES:
State only the ones you've personally experienced -
no electronic analysis or gimmicky test kits)
You must fill in the Visual Check box for security reasons - Thank You
Please press SUBMIT to sent this consultation form.
 
© all rights reserved. No photo or text maybe reproduced in any part or form, without prior consent from www.real-medicine.org