Medical History Form

Completing this form is required before scheduling your consultation. Dr Gouws personally reviews your medical history prior to booking to assess your case and determine if any diagnostic tests or imaging are needed beforehand—ensuring your first visit is efficient, safe, and tailored to your needs.

Name

Please enter your first name.

This field is required.

Surname

Please enter your surname.

This field is required.

ID Number

Please enter your ID number.

This field is required.

Physical Address

Please enter your current physical address.

This field is required.

Telephone Number

Please enter your contact number.

This field is required.

Email Address

Please enter your email address.

This field is required.

Gender

Please select your gender.

Male

Female

This field is required.

Age

Please enter your age.

This field is required.

Height (cm)

Please enter your height in centimeters.

This field is required.

Weight (kg)

Please enter your weight in kilograms.

This field is required.

Medical Aid

Please enter your medical aid and the medical aid number.

This field is required.

Menstrual Cycle

Please specify your menstrual cycle status if applicable.

Regular

Irregular

No longer menstruating/ Not applicable

Allergies

Please list any allergies you have.

Blood Tests/Reports in Last 6 Months

Have you done any blood tests/reports in the last 6 months?

Chronic Illnesses

Please list any chronic illnesses.

Previous Procedures

Please list any previous medical procedures.

Reason for Appointment

Please specify the reason for your appointment.

This field is required.

Who Referred You?

Please enter the name of the person who referred you to the doctor.

This field is required.