New Patient Information Form | Dr Carl Kgabo Tabane

FORM
NEW PATIENT FORM

Patient Details
Full Name
Email
Contact Number

What are you Current Symptoms / Medical Complaints?
When did they Start?
Did you take any meds for you complaints?
If so, Which ones? And When?
When last did you have a Medical Check-up?
Do you have any Chronic Medical Conditions?
Are you take any other medication, including chronic?
Do you have any previous Surgery?
Do you have any allergies?
Do you any Family History of Medical Conditions?
For Females only( if applicable):
Do you have Children?
When was your last Menstrual Period?
Was it normal?
Do you use any contraceptive Methods?
When was your last Pap smear?
Have you ever had a Mammogram or Breast Sonar?
Have you had any other Diagnostic procedure/Pathology tests done on you? If yes, tell us more
When was your last HIV test? Results?
For Males only( if applicable):
When was your last Prostate examination?
Have you had any Diagnostic procedure/Pathology tests done on you? If yes, tell us more