Personal Information

Presenting Complaint

What would you like treating now?

Present Treatment

i.e. pharmaceutical medication / natural medicines / therapies:

Past Illness or Operations

Please list any past conditions and the treatment required:

Family History
Additional Information

List any allergies:

List any vaccines in the past 5 years:

Do you smoke?

If yes, how many cigarettes a day?

Have you given up recently?

How many units of alcohol do you consume per week?

Are you a vegetarian?

Additional Comments

Is there anything else you would like to contribute to this questionnaire?