Medical History Form

Full Name (required)

Email (required)

Phone Number including country code (required)

Address (required)

City (required)

Country (required)

Where did you find us ? (required)

Date of Birth (DD/MM/YYYY) (required)

Weight in kilograms (required)

Height in cm (required)

Do any of these Medical Problems apply to you? Please select yes of those that do.

Heart Disease (required)

Chest Pain (required)

Heart Murmur (required)

High Blood Pressure (required)

Shortness of Breath (required)

Asthma/Emphysema (required)

Blood with Coughing (required)

Anesthetic Reaction (required)

Diabetes (required)

Thyroid Disease (required)

Arthritis (required)

Kidney Stones (required)

Blood in your Urine (required)

Stroke (required)

Nervous Disorder (required)

Blood Transfusion (required)

HIV (required)

Hepatitis (required)

Bleeding Tendency (required)

Stomach Ulcers (required)

Hernia Repairs (required)

Cancer (required)

Please list all the medications you are presently taking

Are you allergic to any medications? (Please list)

Do you smoke?

If yes, how much a day?

Do you drink alcohol (required)

If yes, how much a day?

I read and accept terms and conditions

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