Your Medical History
First Name
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Last Name
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Phone
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Email
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Date of birth
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Occupation
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Emergency Contact Name
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Emergency Contact Phone Number
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Doctors Name
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Doctors Phone Number
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Your Weight
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Less than 21 Stone
Between 21 & 35 Stone
Over 35 Stone
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Do you Currently Have
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Hearing Loss
Sight Loss
Mobility Problems
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Units of Alcohol
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Do you smoke - if so, how many per week?
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Are You Currently
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Receiving Treatment from a doctor, hospital or clinic?
Carry a Medical Warning Card?
Pregnant
Please list any prescribed medicine including any tablets, inhalers, injections, contraceptives or ointments. Please also note any self prescribed medication/drugs including pain killers or recreational.
Upload Medical Prescriptions (if Preferred)
Have you ever had
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Allergies to drugs ( eg penicillin ), plasters, latex or food?
Chest condition such as Asthma or COPD?
Epilepsy or other neurological disorder?
Heart problems | Angina | High / Low Blood Pressure | Stroke | Hear Surgery or Heart Problems
Diabetes?
Bone or joint disease?
Persistent bleeding or bruising after injury / surgery?
Are you taking any anticlotting drugs such as Warfarin or Prothrombin?
Liver disease?
Kidney or urinary tract disease?
Hepatitis B, C or HIV?
Mental health problems ( eg Alzheimer's, dementia, depression )
Learning disability?
Drug or alcohol addiction?
An operation under general anaesthetic?
Any other condition or disability not listed above?
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