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MEDICAL HISTORY QUESTIONNAIRE

Name

DOB

Address

Phone

GPs Name and Address

Do you consent to the use of your PPS No. to check your eligibility for treatment under the PRSI scheme?

If yes please provide PPS no

Do you consent to be recalled by text message/phone call/email for the purposes of continuing treatment and/or routine check-up?

Past Medical History

How is your general health?

Have you consulted a physician for any illness in the last 2 years?

If yes, what was it for?

Are you currently taking, or have recently taken any prescription/ non prescription medications?

If yes, please list

Have you been hospitalised in the last 2 years?

If yes, what for?

Do you have any allergies?

Do you bleed excessively when cut or bruise easily?

Are you currently taking or have you taken cortisone/ steroids?

Do you smoke or use other forms of tobacco?

WOMEN ONLY

Are you, or do you suspect you may be pregnant?

Do you have or have you ever had

Heart disease/ Disorder?

Stroke?

Bronchitis?

Kidney Disease?

Epilepsy?

Hepatitis B/ C?

Heart Surgery?

Diabetes?

Liver Disease?

Arthritis?

Radiation Treatment to Head or Neck?

HIV/ AIDS?

Rheumatic Fever?

Asthma?

Cancer?

Artificial Joints (hip/ knee)?

Shortness of breath?

High Blood Pressure?

Do you have any other serious illness? If so please state

When was your last dental check-up?

Have you recently returned from a trip abroad?

If YES, where have you returned from?

Date

Signed (Patient/ Parent or Guardian)

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