Health Profile Form

Page 1

Full name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone number

Gender

Female Male Non-binary Prefer not to say

Date of birth

Page 2

Profession or occupation

Do you authorise us to contact your GP if needed, for example to recommend a test after the consultation?

Yes No

If you answered yes above, give the name, address, email and phone number of your GP

Describe why you are seeking treatment and the outcome you hope for

Describe any treatment you receive or have received for that reason

List medicines, supplements and vitamins you take, with dose and frequency, including long-term treatments such as contraceptives, an IUD or blood pressure tablets

Medical history: list in chronological order major illnesses, accidents, hospital stays, treatments and traumas, including childhood illnesses and dental work

List allergies and intolerances (food, medicines, pollen, animals, gluten, dairy) and the medicines you use to relieve them

Give your height and current weight

Page 3

Childhood: describe what you know about your birth (full term or premature, induced, caesarean, complications, emergencies)

Childhood: did you feel safe growing up? If not, please explain

Childhood: was there alcohol or drug use at home? If so, please explain

Have you lived through or witnessed violence or abuse? Share as much detail as you feel comfortable with

Family history: illnesses of blood relatives, cause and age of death where relevant, plus any alcoholism, addiction, behavioural problems, birth defects, disabilities, allergies or asthma (grandparents, parents, siblings and children)

List your vaccinations, any reactions and the date given, including travel and COVID vaccines

Page 1

Page 2

Page 3

Page 4

Related templates