Medical History For Male Partner


Medical History:

Do you have any allergies: Please explain:

Do you have any present medical condition? Explain

Have you had hospitalisation for any medical condition? Explain

Are you currently taking any medication (prescribed or over the counter)?

Do you have children from a previous relationship? Number:

Surgical History:

What previous operations did you have?

Family History:

Are there any specific medical conditions within your family? Explain

Social History:

What is your occupation?

Do you smoke? If yes, how many per day?

Do you drink alcohol? If yes, how often?

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