PPS Professional Health Preserver Declaration

PPS Professional Health Preserver Declaration Date of Declaration: 1 November 2024 Applicant Details: Full Name: Sarah Jane Smith Date of Birth: 15/03/1988 Occupation: Marketing Manager Address: 14 Acacia Avenue, London, SW1A 0AA Contact Number: 07700 900345 Email Address: sarah.smith@example.com Medical History: 1. Current Medical Conditions: * Migraines (diagnosed 2010, managed with sumatriptan) * Eczema (mild, occasional flare-ups, managed with topical steroids) 2. Past Medical Conditions (within the last 5 years): * None reported. 3. Hospitalisations/Surgeries (within the last 5 years): * Appendectomy (2018, full recovery). 4. Medications (currently prescribed and over-the-counter): * Sumatriptan 50mg (as needed for migraines) * Hydrocortisone cream 1% (as needed for eczema) 5. Allergies: * Penicillin (anaphylaxis) * Dust mites (rhinitis) 6. Family Medical History (relevant conditions among parents/siblings): * Mother: Hypertension (diagnosed age 55) * Father: Type 2 Diabetes (diagnosed age 60) Lifestyle Habits: 1. Smoking Status: * Non-smoker 2. Alcohol Consumption: * Occasional social drinker (2-3 units per week) 3. Recreational Drug Use: * None 4. Exercise Habits: * Regular (3-4 times per week, mix of cardio and strength training) 5. Diet: * Balanced, generally healthy Declaration of Accuracy: I, Sarah Jane Smith, declare that the information provided in this form is true, complete, and accurate to the best of my knowledge and belief. I understand that any false or misleading information may affect the validity of my PPS Professional Health Preserver policy. Signature of Applicant: Sarah Jane Smith (Electronically signed) Date: 1 November 2024 General Practitioner: Name: Dr. Eleanor Vance Practice Name: City Medical Centre Contact Number: 020 7946 0000 Email Address: dr.vance@citymedical.com