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About you
GP & preferences
Marketing preferences (optional)
Next of kin
Health & medicines
Are you pregnant?
Receiving treatment from a doctor/hospital/clinic?
Taking prescribed medicines?
Medicines
Carrying a medical warning card?
Allergies (medicines, latex/rubber, foods)?
Allergies
Hay fever or eczema?
Bronchitis, asthma or other chest condition?
Fainting attacks, giddiness, blackouts, epilepsy?
Muscle problems (myopathy, dystrophy, paralysis)?
Heart problems (angina, blood pressure, stroke)?
Diabetes (or family history)?
Neurological diseases (e.g. neuropathies, MS)?
Arthritis?
Bruising or persistent bleeding after injury/surgery?
Infectious diseases (incl. HIV, hepatitis, TB)?
Stomach ulcers/hiatus hernia/indigestion?
Lifestyle & consent
Do you smoke tobacco now (or did you in the past)?
Do you chew tobacco/paan/gutkha/supari now (or did you in the past)?
Declaration
Date:
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