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) ………………………….......