(It is important to know that in order for your physician to help you to the best of his / her ability, you need to give clear and full information. Remember the information is confidential & in the case of a psychologist you have the right to ask for information not to be recorded)
Bio data
- Your name and age
- Your marital status (history)
- Where you are currently living and where you have lived before
- Whether you have recently traveled from your current place of residence
- Occupation and how much time you put into it and your daily activities and or changes
Medical History
- Describe as best as you can what has brought you to the clinic and anything strange or odd that you’ve experienced lately e.g. fainting, a swelling anywhere on your body, memory loss etc
- What medications you have taken in the past 3 or so months. Be forthright on whether they are over the counter medications including health supplements, vaccinations, contraceptives, prescription or any other drug even if it is illegal
- Any alternative medical service you have sought e.g. herbal interventions, witchcraft etc. (Remember this information is confidential)
- Any other diseases, conditions, operations (legal or otherwise), allergies, hospitalizations, accidents & injuries etc you are aware of
- What kind of diet you are on e.g. you don’t eat meat or eat it a lot or you don’t like vegetables , what your appetite is like
- Any diseases or conditions that you know run through your family e.g. if you have a sister, brother. parent, aunt or uncle with a mental problem or has/had cancer
- Your social activities & any habits e.g. your hobbies, do you take alcohol, tobacco, recreational drugs, hobbies, sleep patterns (i f not normal)
- In this day and age, your sexual activities and orientation maybe important
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