Medical History Questionnaire

Please take a few minutes to answer the following questions carefully as this assists us in preparing for your assessment. The information from this Questionnaire may be used for research purposes, your personal details will be withheld.

Please tick what is correct – if you are not sure about the answer, leave it blank and ask the doctor at your consultation, thank you.

Your Current Complaint (code YCC)

Your Symptons (code YS)

3. If you experience pain in your legs: (Code 3A)

a. Does your pain get worse:

b. Does the pain get better by: (Code 3B)

Onset of Veins (Code OV)

Past Venous History (code PVH)

6. Have you had any of the following:

Past Medical History (Code PMH)

8. Do you have a history of:

Gynaecological History (Ladies only) (Code GH9)

Surgical History

Family History (Code FH)

18. Do you have a family history of:

Psychological History (Code PH)

19. Do you suffer from:

Social History

Medications

Allergies (Code A1Y A1N)

24. Have you had any of the following allergic reactions?

25. Do you have an allergy to any of the following?

If you answer “’Yes’ to any of the following, please explain what happens if you take them