Medical Assessment Your contact details Medical and Psychiatric History Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions. Have you ever suffered from heart or lung problems? YesNoX Have you ever suffered from liver failure? YesNoX Have you ever suffered from a head injury? YesNoX Have you ever suffered from seizures or fits? YesNoX Have you ever suffered from Asthma? YesNoX Have you ever suffered from blood pressure problems? YesNoX Have you ever suffered from balance problems? YesNoX Have you ever suffered from Diabetes? YesNoX Have you ever suffered from pancreas disorders? YesNoX Have you ever had problems of swelling?(E.g. in the stomach or feet) YesNoX Are you allergic to any medication? YesNoX Have you ever suffered from any mental health problems? YesNoX Have you ever been sectioned under the Mental Health Act? YesNoX Have you ever attempted to harm yourself in any way, for example, taken any overdoses, cutting yourself etc.? YesNoX Have you ever deliberately attempted to kill yourself? YesNoX Medical and Psychiatric History Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions. Are you suffering from any medical conditions at the moment? YesNoX Are you currently taking any medication? YesNoX Have you had a blood test in the last four weeks about which we may contact your doctor? YesNoX Do you currently use any street drugs, for example, heroin, cocaine, cannabis etc.? YesNoX Have you ever undertaken a "detox" for alcohol or drug problems in the past? YesNoX Please provide the name, age and address of the adult who has agreed to supervise your medication, should you be issued with a prescription. When did you last see your doctor? ---This WeekLast WeekThis MonthLast Month3-6 MonthNot recently Are you currently being seen by someone from a community drug or alcohol service? YesNoX Is the above information correct at the time of completing this assessment? Please confirm by printing your name which will constitute as a signature and check the box so that you have read our Service Agreement and that you agree to the terms and conditions it sets out serenity July 18, 2018