The Medical Declaration Form Template UK is offered in several formats, including PDF, Word, and Google Docs, featuring editable and printable samples for your convenience.
Medical Declaration Form Template UK Editable – PrintableSample
Medical Declaration Form Template UK 1. Patient Information 2. Emergency Contact Information 3. Medical History 4. Current Medications 5. Allergies 6. Family Medical History 7. Lifestyle Information 8. Consent for Treatment 9. Confidentiality Agreement 10. Signature and Declaration 11. Declaration and Signatures
PDF
WORD
Examples
[Full Name]
[Date of Birth]
[NHS Number]
[Address]
[Phone Number]
[Email Address]
Please provide details of any previous medical conditions or surgeries:
[Details of Medical History]
List any medications you are currently taking:
[Medication List]
Do you have any known allergies? If so, please specify:
[Allergy Details]
Indicate any significant health issues in your family:
[Family Medical History]
Please briefly describe your lifestyle including diet, exercise, and smoking/drinking habits:
[Lifestyle Details]
Please use the space below for any additional information:
[Additional Comments]
I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that providing false information may result in denied treatment.
[Signature of Patient]
[Date]
[Full Name]
[Date of Birth]
[NHS Number]
[Address]
[Phone Number]
[Email Address]
Have you been diagnosed with any of the following conditions? (Please check all that apply)
– [ ] Diabetes
– [ ] Heart Disease
– [ ] Hypertension
– [ ] Asthma
– [ ] Other: [Specify]
List any previous surgeries along with dates:
[Surgery Details]
List any current treatments or therapies being undertaken:
[Treatment Details]
Please provide details of any allergies, including food, medications, and environmental:
[Allergy Details]
Please provide information about any hereditary conditions present in your family:
[Family Health History]
Please indicate your health goals or concerns that you would like to address:
[Health Goals]
I confirm that the information provided is accurate and complete. I consent to the use of this information for medical assessment and treatment.
[Signature of Patient]
[Date]
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