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Medical History Update Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Information

Title : Prof Dr Fr Mr Mrs Ms Miss Master
Patient Name :
*Last Name :
Middle Name : *First Name :
*Date of Birth :
*Home Address
City :
State :
Postcode :
*Home Phone # :
Mobile Phone # :
Work Phone # :
*Email Address :
Occupation :
Health Insurance :
Member ID # :
Contact person in case of emergency :
Phone/Mobile # :

Medical History

Are you being treated for a medical condition? Yes No
If Yes, Explain :
Medical Doctor:
Doctor’s Address :
City :
State :
Postcode :
Phone Number :
Are you taking any medications or supplements at present, both prescribed or over the counter? (Please list)
Are you taking any bisphosphonate medication or any other medication to treat osteoporosis?
Do you have, or have you ever had, any of the following medical conditions?
Steroid therapy
Rheumatic fever
Epilepsy
Asthma
Diabetes
Heart valve disorder
Stroke
Heart murmur
Kidney disease
Tuberculosis
Eating disorder
Leukaemia, cancer
Nervous condition
Heart complaint or heart surgery
Thyroid disease
Radiation or chemo therapy
High blood pressure
Low blood pressure
Stomach or digestive condition e.g. reflux
Transplanted organ or bone marrow
Cardiac pacemaker
Excess bleeding
Hepatitis or liver disease
Contact with HIV/AIDS virus
Anaemia or Blood Disorder
Prosthetic implant eg. prosthetic hip or knee
Bronchitis, emphysema or other lung disease
Other :
Please list all known allergies (eg penicillin, latex) :
Do you smoke? Yes No How many? /day
For females, are you pregnant or undergoing fertility treatment?
Guardian Name :
Dependents :
Your Signature Date