Name * Maiden name Place of birth * Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Address Permanent * Temporary National Insurance Number (TAJ) * E-mail Telephone * Marital status Single Married Divorced Widowed Do you have a driving licence? * Yes No If yes I. group (owner-driver) II. group (professional) Occupation * Do you have a family history of: Father Living or, how old was he/she when he/she passed away High blood pressure? Infarctus, cerebral Diabetes Cancer (if yes, what type) Congenital disease Respiratory disease Locomotor disease / disorder How old was he/she What type Mother Living or, how old was he/she when he/she passed away? High blood pressure? Infarctus, cerebral Diabetes Cancer (if yes, what type) Congenital disease Respiratory disease Locomotor disease / disorder How old was he/she What type Sibling Living or, how old was he/she when he/she passed away? High blood pressure? Infarctus, cerebral Diabetes Cancer (if yes, what type) Congenital disease Respiratory disease Locomotor disease / disorder How old was he/she What type Grandparent Living or, how old was he/she when he/she passed away? High blood pressure? Infarctus, cerebral Diabetes Cancer (if yes, what typ Congenital disease Respiratory disease Locomotor disease / disorder How old was he/she What type Medical history Do you smoke? * Yes No How many cigarettes do you smoke a day? How long have you been smoking for? (year) Have you ever smoked? Never Yes, I gave up smoking. When? (year) Do you consume any alcohol? * Yes No Occasionally How many times? (per week) How often do you exercise? Regularly Rarely Never How many times? (per week) Are you allergic to any of the following? Medicines Medicines you do not tolerate (e.g. things that can cause vomiting) Chemical Metal Pollen Food Other Previous diseases? – please indicate dates Have you had any operations? – please state kind of operations and dates Have you had any accidents? – please list them Any treated chronic disease? (high blood pressure, diabetes, asthma, reflux disease, etc.) Dou you take any medicines regularly? – Please name them, list dosage, indication (why you take them) and how long have you been taking medicines Are you disabled? If yes, please indicate the level of your disability. When is your next review? When did you have your last health check? Mammography Cervix cancer screening Prostate cancer screening Skin cancer screening Lung screening Any other screenings Do you wear glasses? * Yes No Please provide further details Please indicate your current: Weight (kg) * Height (cm) * Waist size (cm) * What code is in the image? * Enter the characters shown in the image.
