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1. Name, date of birth, sex, weight and height.
2. A family health history, covering the parents, the brothers and sisters (if any) and the other children (if any) of the natural parent with details of any serious physical or mental illness and inherited and congenital disease.
3. Past health history, including details of any serious physical or mental illness, disability, accident, hospital admission or attendance at an out-patient department, and in each case any treatment given.
4. A full obstetric history of the mother, including any problems in the ante-natal, labour and post-natal periods, with the results of any tests carried out during or immediately after pregnancy.
5. Details of any present illness, including treatment and prognosis.
6. Any other relevant information which the agency considers may assist the panel.
7. The signature, name, address and qualifications of any registered medical practitioner who supplied any of the information in this Part together with the name and address of any doctor (if different) who may be able to provide further information about any of the above matters.
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