Health Check Form

Full Name *

Email Address *

Phone Number *

+1

Gender *

Birthday

Height (cm)

Weight (kg)

Address

Country

Smoking

Alcohol

Drug Use

Prescriptions/Medications

Date of last menstrual period

Number of pregnancies

Number of live births

Last childbirth (Date)

Method of birth control (Specify)

If menopausal, date of onset

Drug allergies/adverse drug reaction

No

Yes

Reaction to Anaesthesia

No

Yes

Blood Transfusion

No

Yes

Sexually Transmitted Disease

No

Yes

Hepatitis

No

Yes

HIV

No

Yes

Breast Feeding

No

Yes

Hereditary health concerns

No

Yes

Diabet

No

Yes

Insulin

No

Yes

Oral antidiabetic pills

No

Yes

Blood Pressure

No

Yes

Cancer

No

Yes

Kidney Disease

No

Yes

Epilepsy or Seizures

No

Yes

Anemia

No

Yes

Arthritis

No

Yes

Asthma/Emphysema

No

Yes

Difficulty in Swallowing/Stroke

No

Yes

Abnormal Vaginal Bleeding

No

Yes

Swollen Glands

No

Yes

Anxiety

No

Yes

Reflux

No

Yes

Chest Pain

No

Yes

Shortness of Breath

No

Yes

Difficulty Sleeping/Apnea

No

Yes

Nausea

No

Yes

Dizziness

No

Yes

Murmur (Heart Disease)

No

Yes

Cardiac failure (Heart Disease)

No

Yes

Rhythm disturbances (Heart Disease)

No

Yes

Surgical History

Surgical History Date

Notes

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