Medical History Form

Please complete the medical history form below:

Medical History From
This information will assist me in your consultation; if you have any problems completing this, please let me know and I will help you complete it.
Patient's Contact Details

(Please also complete separate New Patient Registration Form).
Have you ever suffered from the following? (If yes please give details)
Heart disease of any sort:
Chest pain, palpitations or black outs:
High blood pressure:
Rheumatic fever:
Asthma, bronchitis or other chest disease:
Diabetes or sugar in the urine:
Kidney or urinary problems:
Convulsions or fits:
Anaemia or other blood disorders:
Bruising or bleeding problems:
Blood clots in the legs or lungs:
Jaundice (yellowness):
Hepatitis:
Indigestion or heartburn:
Any other serious illness:
Do you have problem scars:
Have you or a family member suffered with problem moles/lesions:
Do you smoke/stopped smoking (How many a day):
Do you have any replacement joints:
Do you have a pacemaker or any implants:
Do you have eyesight or hearing problem:
Could you be pregnant:
Are you on HRT/the pill:
Any Sports or hobbies/Keep fit:
Have you had or had symptoms of Covid-19:
Have you had a test for Covid-19:
Do you or anyone in your household currently have symptoms of Covid-19 (high temperature, continuous cough) or in insolation due to symptoms?
Are you taking any medicines?
Are you allergic to anything? Especially any drugs / dressings / materials:
Please list any previous operations or anaesthetics, year and any complications experienced,
i.e. scars, infections, delayed healing etc:
Have you or a member of your family had problems with Local anaesthetics?
Is there anything else we should know?

I also give my consent to being treated by the Podiatrist and I confirm I am aware that Podiatrists may use sharp medical instruments including nail nippers, scalpel, files and burrs in my treatment and following visits.
By typing your name in the box above this will act as your digital signature.
DD/MM/YYYY
Centre4Feet 1 Ray Lane, Blindley Heath, Surrey, RH7 6LH. 01342 834454

Please ensure you complete the New Patient Registration Form if you have not already done so.