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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) ………………………….......