Patient Questionnaire

Medical Questionnaire

Please detail the following:

Do You have a history of any of the following?
Diabetes YesNo
Heart conditions YesNo
Rheumatoid arthritis YesNo
Cancer or tumours YesNo
Epilepsy or fits YesNo
Asthma YesNo
Headaches or migraines YesNo
High blood pressure YesNo
Bladder or Bowel disorders YesNo
Nerve disorders or neurological conditions YesNo
Digestive problems YesNo
Blackouts YesNo







Drug History

Are you taking any of the following medications:

Steroids YesNo Painkillers YesNo Anti-Inflamitory Medication YesNo


I confirm that the above information is accurate