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  • Date of birth
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    2 digit month, 2 digit day, 4 digit year

  • Do you have, or have you had, any of the following?

  • Chest pain / heart pain / heart attack?
  • High blood pressure?
  • Stroke?
  • Asthma?
  • Epilepsy?
  • Diabetes?
  • Peptic ulcer disease / stomach problems?
  • Mental problems e.g. anxiety/depression?
  • Kidney disease?
  • Tuberculosis or other infectious diseases?
  • Cancer?

  • Do you currently have any of the following?

  • Back pain / joint pain (muscle and joint pain)?
  • Hernia?
  • Eye problems (apart from glasses)?
  • Gastritis?
  • Hepatitis or gall bladder disease?
  • Change in bowel habit / diarrhoea?
  • Blood in stools / piles / haemorrhoids?
  • Shortness of breath?
  • Recurrent bronchitis / pneumonia?
  • Blood in urine or kidney stones?
  • Headaches / migraine / dizziness?
  • When did you last visit your dentist?
     - -
    2 digit month, 2 digit day, 4 digit year

  • I certify that the above information is correct:

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

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