Basic Medical Record | Webform Portal - Paperless Mission Control

Medical Record

Date: *

Client Details

Client Name: *

Date of Birth: *

Email: *

Address: *

Postcode: *

Contact Number: *

How may we contact you?

Text Email Post

Medical History

Please complete the following medical questionnaire:

Are you on any current medication: *

Yes No

If Yes please give details:

Are you pregnant or breast feeding? *

Yes No

Have you a history of severe allergy/anaphylaxis? *

Yes No

Are you currently receiving any medical treatment? *

Yes No

If yes, please give more details

Have you ever suffered form auto-immune disease affecting the immune system? *

Yes No

(e.g. rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, Crohn's disease, lupus erthematosus, polyarteritis nodosa/scleroderma/polymyositis, Sjogren's syndrome, Grave's disease, ankylosing spondylitis, etc).

Are you susceptible to hypertrophic scarring? *

Yes No

Do you suffer from any allergies? *

Yes No

Any other medical conditions: *

Yes No

If yes, please give more details

Please inform your clinician/therapist of any other conditions/medical history we may need to know about.

Client signature:

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.