TOTAL HEALTH CLINIC

PATIENT DETAILS

Personal information

Example

Name Julie Anne ... Garcia

Contact phone:              (1) 219 442 9785

Date of birth:                 (2) 10(th) October, 1992

Occupation:                  works as a (3) manager

Insurance company:       (4) Cawley Life Insurance

Details of the problem

Type of problem:           pain in her left (5) knee

When it began:              (6) 3 weeks ago

Action already taken:     has taken painkillers and applied ice

Other information

Sports played                belongs to a (7) tennis club

                                    goes (8) running regularly

Medical history             injured her (9) shoulder(s) last year

                                    no allergies

                                    no regular medication apart from (10) vitamins