Patient Classification Personal DetailsPatient Name* First name Last name Email address* Gender* Male Female Gender diverse Gender diverse* (please state)Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height (cm)*(in centimetres)Weight (kg)*(in kilograms)Mobile PhoneHome PhoneEmployer's DetailsEmployment status* Currently employed Unemployed or Retired Occupation* Company name* Phone number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Smoking StatusStatus* Current smoker Recently quit Past smoker Non-smoker If you are a past smoker or recently quit, when did you quit smoking?*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(approximate date acceptable)If you are a current smoker, how many do you smoke per day?*If you are a current smoker, would you like support to quit smoking?* Yes No Alcohol StatusQuantity* Non-drinker 1-2 standard drinks daily 4-5 standard drinks daily Special occasions only ClassificationsDo you suffer from any of the followingConditions Heart issues Diabetes Asthma Allergies Allergies* Please specifyDo you take Warfarin* Yes No Family HistoryExcluding yourself. Please give details and family member.Heart problems* Yes No Heart problem details*Please give details and family member(s)Stroke* Yes No Stroke details*Please give details and family member(s)Cancer* Yes No Cancer details*Please give details and family member(s)Diabetes* Yes No Diabetes details*Please give details and family member(s)Other* Yes No Other details*Please give details and family member(s)CommentsComment on any relevant past medical history not mentioned in this form.Screening History(female only)Date of last MammogramDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(approximate date acceptable)Date of last Cervical SmearDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(approximate date acceptable)Next of KinName* First Last Relationship* Phone*Address* Street Address Address Line 2 City State / Province / Region
