Patient Health Information
Name: ______D.O.B.______/______/____
Red Hill Doctors Surgery regards your personal information as very important and private. A complete Family History and Social History enable us to provide you with the best quality holistic healthcare. We respectfully request you fill out the information below as completely as possible.
Country of birth: ...... Languages spoken: ......
Allergies
It is very important to list any known allergies you may have.
Or I have no known allergies qFamily Medical History:
q Unknown (eg Adopted) q No significant Family Medical History
Age at Death Cause of death
Mother Alive? qYes qNo …………….. ………………………………….
Father Alive? qYes qNo …………….. ………………………………….
Significant Family Medical History:
Mother: qDiabetes qHypertension qHeart Disease qStroke
qColon Cancer qDepression qBreast Cancer
qAnything else?......
Father: qDiabetes qHypertension qHeart Disease qStroke
qColon Cancer qDepression
qAnything else?......
Other Family members:
Relationship / Condition / CommentYour Medical History:
Any further medical information you would like to share:
Social History:
Marital Status: qSingle qMarried qDeFacto qSeparated qDivorced qWidowed
Sexuality: q Heterosexual q Homosexual q Bisexual q Other
Elite Athlete: qYes qNo
Recreational Activities:
Accommodation:
qOwn home q Renting qRelatives qHostel qOther private house qNursing home qOther
Lives with:
qSpouse/Partner qRelative qFriend q Alone
Is a Carer: qYes qNo qSelf
Has Carer: qYes qNo qSelf
Carer details
Name / Address / Phone / Alternate contact / RelationshipIs there anything else you would like us to know about you?
OCCUPATION:
Current Occupation: Retired: qYes qNo
Previous Occupations:
Occupation / Employer / Approx Start date / Approx Finish dateALCOHOL CONSUMPTION
Current Alcohol Intake:
Non Drinker qYes qNo (if no please fill in the boxes below)
Days per week / Description /Type consumed eg: beer/wineStandard Drinks per day / Weekend consumption eg:Friday - Sunday
Standard Drinks table:
Did you know?1 standard drink = 10g alcohol
This amount of alcohol is contained in:
· 285ml of ‘heavy’ beer (middy, pot, 10oz)
· 375ml stubby ‘mid strength’ beer
· 120ml glass of table wine
· 60ml glass of port, sherry
· 30ml nip of spirits
Past Alcohol Intake:
qNil qOccasional qModerate qHeavy
Year Started / Year StoppedComments or Concerns:
CURRENT SMOKING HISTORY
q Non Smoker
q Ex-smoker - Past smoking history:
q Cigarettes q Cigars q Pipe q Other
q Light q Moderate q Heavy
Year Started: ……………….. Year Stopped: ………………..
q Smoker -
q Cigarettes q Cigars q Pipe q Other
q Light q Moderate q Heavy
Year started: ……………….. Number per day:…………………….
Comments or Concerns: