1. Personal Details

What is your title? First name: Surname: Date of birth: What is your sex? Home address: Postcode: Home phone number: Mobile phone number: Email address: What is your occupation?

2. Medical Questionnaire

Are you currently receiving care or treatment from a doctor, hospital or clinic? Are you taking any medications at the moment (including things like tablets, ointments, inhalers or injections)? Do you carry a medical warning card? Are you pregnant or think you may be? Do you have any allergies (such as to medicine, latex, rubber, or foods)?

3. Medical History

Have you had any breathing or chest problems (such as asthma or bronchitis)? Have you experienced fainting, blackouts, dizziness or seizures? Have you had any heart or circulation conditions (such as angina, stroke, high blood pressure)? Do you have diabetes, or does anyone in your family have it? Have you ever been diagnosed with a bone or joint problem? Do you bleed or bruise more than expected after injury or dental treatment?

4. Lifestyle Information

Do you have or have you had liver or kidney disease (including hepatitis or jaundice)? Have you ever had a serious illness or been told you had an infectious condition? Have you ever refused blood from the Blood Transfusion Service or another source? Have you ever had a reaction to general or local anaesthetic? Have you had hospital treatment or surgery that required you to stay overnight? Have you had heart surgery or a stent fitted? Do you have any mental health conditions (such as anxiety, stress, depression or eating disorders)?

5. Additional Information

Full name of your emergency contact: What is their relationship to you? Emergency contact phone number: Are you exempt from NHS charges? If yes, please tell us the reason for exemption:

6. Marketing Communication Preferences

Do you consent to us contacting you for updates, reminders or information? If yes, how would you prefer to be contacted? PhoneEmailText message Would you like to receive invitations and information about our Open Days? If yes, how would you prefer to be contacted? PhoneEmailText message

7. Declaration

I confirm the information I have provided is correct.

5 + 6 =

01467 629 909

Medical History Form