Medical Questionnaire

1. Attending or receiving treatment from a Doctor, hospital, clinic or specialist?

2. Taking or using any prescribed medicine, tablets, inhalers or any other drug? (including Contraceptives or HRT)

3. Allergic to any medicine, foods or materials?

4. Expecting a baby?

5. The mother of a child under 12 months?

1. Had rheumatic fever or chorea?

2. Had jaundice, liver, kidney disease or hepatitis?

3. Ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack?

4. Ever had your blood refused by the Blood Transfusion Service?

5. Had a joint replacement?

6. Taken steroids in the last two years?

7. Have you ever had any form of cancer?

8. Have you ever taken medication to treat Osteoporosis?

4. Have a pacemaker, or have you had any form of heart surgery?

5. Suffer from bronchitis, asthma or any other chest condition?

6. Have fainting attacks, giddiness, blackouts or epilepsy?

7. Have diabetes or does anyone in your family?

8. Bruise easily or following a tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried?

9. Have any infectious disease (including HIV, hepatitis or vCJD)?

10. Do you carry a medical warning card?

Are there any other aspects concerning your health that we should know about?

The information provided will be treated in the strictest confidence.

If there are any amendments/additions to your medical history, please inform us immediately.

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