I consent to receive communication from Clermont Country Practice via SMS as per the contact numbers I have provided on this form, this may include third party communications through our Best Practice software or our appointment reminder system - Automed.
Heart disease (heart attack, angina, stents, abnormal heart beat)
NoYes
High Blood Pressure
NoYes
Diabetes or raised blood sugar levels
NoYes
Blood clots in legs or lungs
NoYes
Depression and/or anxiety
NoYes
Asthma, COPD, or other lung disorders
NoYes
Bleeding or clotting disorder
NoYes
High cholesterol
NoYes
Stroke or brain haemorrhage
NoYes
Stomach ulcers, bowel problems, or other abdominal disorder
NoYes
Eczema, psoriasis, dermatitis, or other skin disorders
NoYes
Epilepsy, fits, convulsions or blackouts
NoYes
Migraines
NoYes
Back or spinal problems
NoYes
Any cancer/tumor, including skin cancer
NoYes
Osteo – Rheumatoid arthritis or other joint condition
NoYes
Surgical history/operations
NoYes
Others
NoYes