Parents play a ________ role in a child’s upbringing in the formative years. They are really the driving force behind whatever the children do.

TOTAL HEALTH CLINIC

PATIENT DETAILS

Personal information

Example

Name Julie Anne ... Garcia

Contact phone:             (1) ………………………………….

Date of birth:               (2) …………………………………., 1992

Occupation:                 works as a (3) ………………………………….

Insurance company:     (4) ………………………………….Life Insurance

Details of the problem

Type of problem:         pain in her left  (5) ………………………………….

When it began:             (6) ………………………………….ago

Action already taken:   has taken painkillers and applied ice

Other information

Sports played               belongs to a  (7) ………………………………….club

                                    goes  (8) ………………………………….regularly

Medical history            injured her  (9) ………………………………….last year

                                    no allergies

                                    no regular medication apart from  (10) ………………………….......