Registration | General Medical Practice | Doctors @ Bayside

Are you diabetic?

Yes No

Do you have high blood pressure?

Yes No

Have you ever suffered from shortness of breath or chest pain?

Yes No

When was your last PAP SMEAR (Only for Female)?

Have you been in hospital in the last 12 months?

Yes No

If yes what for and when?

Please list all current medications including over the counter medications, vitamins and minerals.

Do you have any allergies or are you sensitive to drugs or dressing? please list.

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