Genital Warts

Name:

Address:

Postcode:

Home Phone:

Work Phone:

Mobile Phone:

Email:

Date of Birth:

Occupation:

Any heart problems or heart surgery

High or low blood pressure

Artificial or prosthetic joints eg hips or knees

Rheumatic fever

Heart murmur

Cardiac pacemaker

Stroke

Circulatory problems

Anemia or blood disorders

Excess bleeding or bruising

Radiotherapy

Chemotherapy

Leukaemia or cancer

Transplanted organs or bone marrow

Epilepsy

Diabetes type I or II

Thyroid disease

Asthma

Tuberculosis

Bronchitis/ emphysema or other lung disease

Hepatitis A/B/C/D/E

Any other liver disease

Kidney disease

Contact with HIV or AIDS virus

Steroid therapy

Stomach or digestive conditions

Eating disorders

Nervous condition

Sinus/tonsils/adenoid problems

Arthritis

Allergies to local or general anaesthetic

Allergies to latex

Allergies or adverse reactions to any medicines

If so, please list:

Do you have or have you had any other serious medical conditions?

Yes No

if yes, please specify

Are you taking any medicines, drugs or tablets, both prescription or over the counter?

Yes No

if yes, please specify

Type / name dose reason for taking

Are there any other medical conditions or risks you wish to discuss?

Yes No

if yes, please specify

Females, are you pregnant or undergoing fertility treatment?

Yes No

if yes, how many months?

Do you smoke?

Yes No

if yes, how much

Do you drink Alcoholic?

Yes No

Do you take any drugs?

Yes No

Where you engaged in any sexual intercourse?

Yes No

Where you engaged in Oral Sex?

Yes No

Where you engaged in anal Sex?

Yes No

When was the first you were diagnosed with genital warts (HPV)?

Please include clear pictures for all your warts in all body locations

Health History Form

Do you have, or have you ever had, any of the following medical conditions?

Do you have, or have you ever had, any of the following medical conditions?