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Medical History Questionnaire

Please fill out this medical history questionnaire accurately so that we can give you the best possible service. The information you provide will be kept confidential and is protected by law.
START
Nice to meet you, please tell us your name.
SUBMIT
What do you do for a living?
SUBMIT
Please enter your date of birth (DD/MM/YYYY)
SUBMIT
Do you have any allergies or adverse responses to medication?
Please list all known allergies and adverse responses to medication.
SUBMIT
Are you currently taking any medication?
Please list the medication you are taking.
SUBMIT
Have you ever been hospitalized?
Please describe the illness or injury you were treated for.
SUBMIT
Do you suffer from any chronic diseases?
Please describe them.
SUBMIT

How can we contact you?

Please give us your email and phone number so that we can contact you with any further questions.

Please fix the errors below and submit again
*
Thank you! Your details are safe with us.
Thank you for filling out this questionnaire.
Your responses will be kept confidential. The information you shared with us will only be used to maintain your health and well-being.

Medical History Questionnaire

Use this questionnaire to learn about the health of new patients, clients, or employees.
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