Medical history form

Full Name

Date of birth

Address

Postcode

Phone

Mobile

Your Email

Occupation


Medical questionnaire

Do you have or have you previously suffered from:

Heart problems (including heart murmur)Blood or circulation problemsKidney or liver diseaseThyroid problemsChest problems (eg Asthma or Bronchitis)High blood pressureBlood borne viruses (eg Hepatitis of HIV)Diabetes Epilepsy

Have you taken steroids in the last two years?

YesNo

Do you take asprin regularly?

YesNo

Are you taking any medication for bone conditions such as Osteoporosis Bisphosphonates?

YesNo

Please give details of allergies to any medicines, food or latex:

Do you smoke?

YesNo

Are you pregnant?

YesNo

Is there anything else you think we need to know, please give details:

Date