Patient Name and Surname
Date of Birth
What is the main reason for your visit
Do you have any allergies?
Are you taking any medication?
Blood Pressure ProblemsHepatitasUse tobacco productsThrembosis/EmbolismChest painDiabetesRheumatic feverMental health disorderSleep and / or snoring problemsJaundiceAIDS or HIVHeart problemsTuberculosisOsteoporosisCancerConditions that effect immune systemTonsil and / or adenoid problemsLiver diseaseShortness of breathPacemakerAsthmaStomach ulcersThyroid problemsJoint replacementEmphysema / Chronic BronchitisArthritis / Rheumatoid ArthritisAbnormal bleedingAbnormal BruisingSinus problemsSeizure disorderKidney disease
Person completing the form (Name and Surname)
Relation to patient (Mother/Father/Guardian)
Date
Signature
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