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Medical Questionnaire

Medical Questionnaire

Personal Information

Your health status

We'll always let you know about important changes, but you pick what else you want to hear about.

Are You Currently Receiving Any Medical Treatment From A Doctor/Hospital/Clinic?
Are You Taking Any Prescribed Medicines?
Are You Allergic To Any Food, Medicines Or Substances? (e.g. Latex Or Penicillin...)
Do You Have Bronchitis, Asthma Or Any Other Chest Condition?
Do You Suffer From Fainting Attacks, Giddiness, Blackouts Or Epilepsy?
Do You Have Heart Problems, Angina, Blood Pressure Problems Or Stroke?
Diabetes
Do You Have Bruising Or Persistent Bleeding Following Injury, Tooth Extraction Or Surgery?
Do You Have Any Infectious Diseases?
Do You Have Any Other Serious Illness?
Have You Had Treatment Which Required You To Be In Hospital?
Other Medical Conditions