Medical History Form
This is a confidential record of your contact details and you health profile summary. Please complete this form in order to proceed with your treatment.

Patient's Health

Please tick which of the following have caused you problems either recently or in the past

Childhood Diseases

Please tick the childhood diseases you/the child has had:


Please list any vaccinations you/the child has had. Did you/they experience any side effects or adverse reactions to the vaccinations?


Please list any operations you/the child has had and at what age you/they had them.


Please list any medications you/the child is taking (prescribed and others)

Homeopathic and other remedies

Please list any homeopathic and other types of remedies previously taken or you/they are taking now.

Family Medical History

Please indicate major illnesses, long term conditions health issues or anything unusual for the following family members
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