Medical History Form

Patient Identifier Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical History

Do you recieve treatment from the doctor or hospital? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been admitted to hospital or had surgery within the last 2 years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently taking any medications? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any known allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you drink alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many units per week? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What do you smoke, and how many per day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medications {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

File Upload {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please list allergies: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do You Suffer From Heart Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Heart Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer From Breathing Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Breathing Poblems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer From Stomach or Abdominal Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Stomach or Abdominal Problems: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer From Skin Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Skin Problems: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer from Epilepsy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Epilepsy Problems: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer from Diabetes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Diabetes Problems: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer From Liver Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes please give details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer From Kidney Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes please give details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Sufffer From Bone or Joint Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Suffer with Bleeding Problems? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Have Any Blood Bourne Infections? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have You Had Any Major Injury or Surgery? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes please give details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had a bad reaction to local or general anaesthetic? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes please give details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

COVID 19 Screening

Check all that apply to you or your immediate family: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any of the following symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you live with someone who has either tested positive for COVID19 or had symptoms in the last 14 days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been notified by NHS Test and Trace in the last 14 days that you are a contact of a person who has tested positive for COVID19 and you do not live with that person? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signatures {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}