Fill Out our patient history form

Kindly complete the form below.

*Procedure of Interest:

Patient Details

*First Name:

*Last Name:

*Date of Birth:

ID Number:

*Phone Number

*Age

*Email

Next of Kin Details

*Name and Relationship

*Phone Number

*Email

Medical Aid

*Medical Aid Scheme and Plan:

*Medical Aid Number:

*How did you hear about us?

*Briefly describe what symptoms brought you to us?

Medical History

*Medical historyPlease indicate whether you suffer from any of the following conditions:

If other please specify:

*Gynaecological history:

If other please specify:

*When was your last menstrual period?

*When was your last PAP smear?

Pregnancy History: Number of pregnancies, Number of children, Miscarriages, Pregnancy complications

*What are you symptoms?

*Height (in meters):

*Weight (in KG):

*Please indicate whether you have been diagnosed with HIV?

*Latest CD4 count and date performed:

*Are you taking ARV medication:

*Medication:Please list your current medication (including supplements) with doses below:

*Family history: Please indicate if you have any family history of chronic conditions:

*Please indicate if you have any allergies?

If yes, please detail what you are allergic to and your reaction (rash/shortness of breath/collapse)?Medication & reaction experienced:

*Are you allergic to seafood/iodine?

*Have you ever had an allergic reaction to the dye (contrast) used during CT scanning?

*Surgical history: Please indicate if you have had any surgery and when? (Previous surgeries and year)

*Please let us know if you have any specific questions that you would like our doctor to discuss with you:

Fill Out our patient history form

Patient Details

Next of Kin Details

Medical Aid

Medical History

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