Web Site Your Contact Details First Name * Last Name * Email Address * Address Suburb State Postcode Phone * Date of Birth About You General Health Do you have or have you had any of the following? (Please check all that apply) Heart trouble High blood pressure Chest pain Heart murmur Stroke Bruising / bleeding problems Cancer Thrombosis-blood clots Asthma Breathing problems Fits / epilepsy / blackouts Anemia Indigestion / heartburn Kidney disease Neurological disorders Jaundice or hepatitis Diabetes Persistent cough Sleep apnoea Have you had any recent blood tests? Yes No I am not suffering from nor have I suffered from Haemolytic Anaemia, G6PD or other Blood Dyscrasias Yes No Have you had any previous operations? Yes No Please specify the operation/s you have had Are you allergic to any drugs or substances? Yes No Please specify any allergies to drugs or substances Are you currently taking any drugs or medications including puffers or patches prescribed or not prescribed? Yes No Please specify what drugs or medications you are taking Are you pregnant, breastfeeding or trying to conceive? Yes No I confirm that the above information I have supplied is true and correct * Yes No Comments / Questions
