Medical Form

Family illness (select): DiabetesHypertetionCancerKidney DiseasesMental Illness

Personal History

Do you smoke or smoked:
Do you consume or consumed alcoholic beavers?
Have you used illegal drugs?

Has had previous surgeries?
If is yes witch?

For women only

Are you pregnant?
Number of living children?
Number of cesareans section?
Method of birth control?


CancerHearth DiseasesHigh blood pressureKidney DiseasesMental IllnessTuberculosisConvulsionsAsthma or BronchitisCastric UlcersHepatitisBlood diseasesPalpitationsGlaucomaParasitesAnemiaArthritis
Do you require?
StickCrutchesWheelchairWalkerSpecial CutlerySpecial Chair AdaptedOthers
List all the medication you take
Do you have allergies?
In case of an emergency a Name and Contact number (Family preference)