☎ 0330 113 2003

Your medical history

This helps us prepare and treat you safely. It takes about 3 minutes. A carer or family member can complete it for the patient.

About the patient

Patient's full name

Date of birth

Postcode

Phone

Email

I'm a carer/family member completing this for the patient

Health

Do any of these apply? (tick all that apply)

Heart condition High/low blood pressure Diabetes Stroke / TIA Respiratory (asthma/COPD) Epilepsy Bleeding disorder / blood thinners Pregnant Latex/other allergy None of these

Medications you take (optional)

Allergies (optional)

GP name & surgery

Emergency contact (name & phone)

Declaration

Completed by

Signature (type your full name)