Patient Medical Report Form Template

Patient name

Date of birth

Email address

Phone number

Country

Address

Height (cm)

Weight (kg)

Please answer these about the patient

Question	Yes	No	Not sure
Currently under the care of a doctor
Allergic to any medication
Any food or environmental allergies
Ever had tuberculosis, or a positive TB test
Ever seen a mental health professional
Ever restricted eating for any reason

Has the patient been diagnosed with a long-term condition?

YesNoNot sure

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Close relatives

Anything else about the family history?0 / 500 characters

I have explained the Privacy Notice to the patient, and the answers above are recorded as given.

Patient medical report