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) ---YesNoChest Pain (required) ---YesNoHeart Murmur (required) ---YesNoHigh Blood Pressure (required) ---YesNoShortness of Breath (required) ---YesNoAsthma/Emphysema (required) ---YesNoBlood with Coughing (required) ---YesNoAnesthetic Reaction (required) ---YesNoDiabetes (required) ---YesNoThyroid Disease (required) ---YesNoArthritis (required) ---YesNoKidney Stones (required) ---YesNoBlood in your Urine (required) ---YesNoStroke (required) ---YesNoNervous Disorder (required) ---YesNoBlood Transfusion (required) ---YesNoHIV (required) ---YesNoHepatitis (required) ---YesNoBleeding Tendency (required) ---YesNoStomach Ulcers (required) ---YesNoHernia Repairs (required) ---YesNoCancer (required) ---YesNoPlease list all the medications you are presently taking Are you allergic to any medications? (Please list) Do you smoke? ---YesNoIf yes, how much a day? Do you drink alcohol (required) ---YesNoIf yes, how much a day? I read and accept terms and conditions