Patient Safety Checklist and the required information


You should understand the medical examinations and procedures that are set to be conducted on you by our professional medical team. Filling out the form below, or helping fill it out will not only aid the medical staff in comprehending and adopting the right procedures for you but also present you with information on the procedures adopted by the medical team. Please fill out every detail of the checklist and seek assistance where you experience difficulty.

Do you understand English:               yes                   no

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Would you need assistance in filling out the form                 yes                   no



Checklist filled out by: __________________________________________________________

Patient’s Name: ____________________________________

Patient’s Age: _______________

Name of Patient’s Guardian if below 18 years old; ________________________________________________________________

Name of Doctor to be visited for the appointment: _______________________________________________________________________

Appointment details;

Date: _________________

Time: _________________

Venue: ________________________________ (room number, clinic, hospital)

Appointment Reasons: ____________________________________________________________________________________________________________

What means do you intend to use to meet the appointment:

Drive           Taxi                     Flight

Train            Cycle                   Train



Please circle out the part of your body in which you are most affected

Please note to avail the following requirements for the appointment

Used medicine packages and bottles

Documents showing medical history/records (X-ray,CT Scans, Prescriptions, MRI                         Scan,etc)

Identification: Passport/ ID with picture

Insurance documents/card

Hospital Clinic Card

The Patient Safety Checklist



Emergency contact’s name: ____________________________________________________ Residence:__________________                   Telephone Number: ________________________

Primary Doctor’s Name: _________________________________________________ Contact;    Telephone: _____________________      Address: __________________

Do you have a Medical Attorney or a Medical Will?

yes       I will avail the document related to this for our next meeting

no        I need more information on this and will contact my doctor




Are you on any supplement (vitamins, medication or any special diet)

yes                   no

If yes, provide the full list of whichever supplement you are using:

  1. ______________________________
  2. ______________________________
  3. ______________________________
  4. _____________________________
  5. ______________________________

Have you ever had any allergic reaction to     drugs and or                food and any   other substance.


If no, list all the materials regardless of the intensity of the reaction:

  1. _________________________________
  2. _________________________________
  3. _________________________________
  4. __________________________________
  5. __________________________________
  6. __________________________________

I have the following medical complications:

Sight Problems

Hearing Problems

Eating Problems

Problem with bones (pain, athritis,     stiffness)

Mental Instability/ illness




Do you have any phobias

yes                   no

If yes, please indicate:


List any other medical complication you have: ____________________________


I have the following medical history:

Cardiac Diseases

Diabetes I or II

Seizures and fainting


Glaucoma and cataract/ Eye problems

Respiratory problems

Mental problems

Intestinal Problems

Blood pressure diseases

Blood diseases

Liver diseases

Kidney diseases

Blood transfusion complications


I am currently under               physiotherapy

chemotherapy              radiotherapy

No therapy



Please all the kind of medication you are under, taking note to fill every detail of the medication

  Name of Medicine Dosage

(e.g. 10mg)

How Many times in a day? Do I have to take the medication forever?
1       Yes   No  
2       Yes   No  
3       Yes   No  
4       Yes   No  
5       Yes   No  
6       Yes   No  
7       Yes   No  
8       Yes   No  
9       Yes   No  
10       Yes   No  
11       Yes   No  
12       Yes   No  
13       Yes   No  
14       Yes   No  
15       Yes   No  


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