Medical History Form

Check all that apply to you or your immediate family (parents, siblings, grandparents)

Asthma/ Lung Problems
History of Back Pain
Diabetes
Cancer
Hypertension
Seizure Disorder
Cardiac Disease
Psychiatric Disorders
Stroke

Check all symptoms you are currently experiencing

Allergy
Eye
Musculoskeletal Pain
Cardiovascular
Fever
Neurological
Chest Pain
Gastrointestinal
Psychiatric
Diabetes
Skin
Respiratory
Eating Disorder
Hemtalogical
Weight Gain
Ear / Nose / Throat
Lymphatic
Weight Loss

Please list any medication allergies that you have :

Please list any medications you are currently taking (and dosage if known) :

Yes
No
Yes
No
Yes
No
Yes
No

Please describe your alcohol consumption :

Daily
Monthly
Rarely
Weekly
Occasionally
Never

Our Locations

We are based in the heart of the world-renowned medical districts of London, Dubai and Abu Dhabi

London
The Elixir Clinic

Wimpole Street:
3rd Floor, 75 Wimpole Street
W1G 9RS, London
United Kingdom

Harrods Wellness Clinic:
Harrods, 87-135 Brompton Road
Knightsbridge, SW1X 7XL, London
United Kingdom

10 AM to 9 PM
Monday – Friday
10 AM to 5 PM
Sunday

Dubai
The Elixir Clinic

33rd Floor, Al Habtoor Business
Towers Opposite Habtoor Grand
Hotel, Dubai, UAE

9:00 AM to 7:00 PM
Saturday – Thursdays

Abu Dhabi
The Elixir Clinic

Villa A04 Al Marina, Marina Village
Next to Marina Mall
Abu Dhabi, UAE

9AM to 9PM (Saturday – Wednesdays)
9PM to 7PM (Thursdays)

Al Ain
The Elixir Clinic

Al Jimi, Opposite Al Jimi Supermarket
Al Ain, UAE
By Appointment Only