Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place
Have you ever suffered from? (tick as appropriate)
If yes, please state the year(s) when were you first diagnosed?
Please list any medicines being taken and the amount:
Are you registered disabled?
*
If yes, please give details
Are you allergic to any medicines?
*
Have you ever refused treatment/screening of any kind?
*
Have you ever suffered from? (tick as appropriate)
If yes to any of these, please state the year(s) when were you first diagnosed?
Do you have any other mental health issues?
*
Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)