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Hospitalisation for illness or injury
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An Allergic reaction to |
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Aspirin, ibuprophen, codeine
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Penicillin
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Erythromycin
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Tetracycline
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Sulphur
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Local anaesthetic
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Metals (nickel, gold, silver)
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Latex
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Other
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Heart problems |
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Cardiac stent within last 6 months
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Infective endocarditis
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Repaired heart defect
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Pacemaker
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Rheumatic fever / scarlet fever
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Other
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Stroke (taking blood thinners)
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Previous hip / knee replacement
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High or low blood
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High cholesterol
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Anaemia or other blood
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Respiratory
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Liver problems (Cirrhosis, jaundice)
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Kidney
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Emphysema
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Tuberculosis
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Diabetes
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Gastrointestinal problems
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Osteoporosis / osteopenia
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Thyroid, parathyroid disease
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Hormone deficency
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Arthritis
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Sexual transmitted disease/ infection
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Viral infections or cold sores
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COVID-19 virus/ influenza
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Hives, skin rashes hay fever
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HIV / AIDS
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Please circle relative type: Hepatitis (type: A, B,C)
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Head or neck injuries
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Epilepsy, convulsions (seizures)
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Neurological problems (ADHD)
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Emotional problems
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Psychiatric treatment
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Treatment for depression
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Cancer treatment
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MALE: prostrate disorder
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