Physical Health History Form

Tell us about your physical health history

Please complete this form before your assessment. It helps us understand any physical health factors that may be relevant to your care.

Please check these details before continuing.

Patient ID

Full name (required)

Email address (required)

Phone number (required)

Tell us about any ongoing physical health conditions.

Do you have any ongoing physical health conditions? (required)

Physical health condition details

Thyroid problems? (required)

Kidney or liver disease? (required)

Glaucoma? (required)

Raynaud’s disease? (required)

These questions help identify any heart-related safety concerns.

History of heart disease? (required)

Blood pressure problems? (required)

Palpitations? (required)

Chest pain? (required)

Dizziness? (required)

Fainting or unexplained falls? (required)

Heart / circulation details

Please provide these if known.

Height

Weight

Blood pressure, if known

Pulse / heart rate, if known

Anything else you would like Dr Musa to know about your physical health?