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PATIENT INFORMATION
Title
Surname
Initials
First Name
Male
Female
Date of Birth
ID. No. / Passport No
Who Referred you to this Practice?
Residential Address
Work Address
Postal Address
Home
Work
Cell
Fax
Email
Medical Aids Name
Number
PERSON RESPONSIBLE FOR ACCOUNT

Title
Surname
Initials
First Name
Male
Female
Date of Birth
ID. No. / Passport No
Residential Address
Work Address
Postal Address
Telephone Number: Home
Work
Cell
Fax
Email
CONTACT NUMBER OF A FRIEND OR FAMILY
Name
Telephone Number: Home
Work
Cell
Have you ever suffered from any of the following:
Rheumatic fever  
Kidney/bladder problems
Diabetes  
Hepatitis/liver disease
High/low blood pressure  
Epilepsy
Radio/chemo therapy  
Psychiatric treatment
Frequent headaches  
Arthritis
Eye/earache  
Aneamia
Sinus problems  
Bleeding problems
Cardiac disease  
Porphyria
Asthma/bronchitis  
Are you taking cortisone steroids
Lung problems  
Are you pregnant
Digestive system problems  
AIDS/HIV
Any other illnesses
Any operations in the past five years
Are you at present receiving medical treatment
State all medicines, tablets or injections presently being used
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