Patient DOB*

Patient Email*

Patient Phone*

GP details

Are you currently receiving treatment from a doctor, hospital or clinic?* —Please choose an option—YesNo

Are you taking any prescribed medicines?* —Please choose an option—YesNo

Do you have allergies to any medicines, substances or food?* —Please choose an option—YesNo

Do you suffer from hay fever or eczema?* —Please choose an option—YesNo

Do you have bronchitis, asthma or other chest conditions?* —Please choose an option—YesNo

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?* —Please choose an option—YesNo

Do you have heart problems, angina, blood pressure problems, or stroke?* —Please choose an option—YesNo

Do you have any other serious illness?* —Please choose an option—YesNo

Have you ever had blood refused by a Blood Transfusion Service?* —Please choose an option—YesNo

Have you ever had a bad reaction to general or local anaesthetic?* —Please choose an option—YesNo

Have you a joint replacement or other implant?* —Please choose an option—YesNo

Have you had any treatment that required you to be in hospital?* —Please choose an option—YesNo

Have you had heart surgery?*—Please choose an option—YesNo

Do you smoke tobacco products now (or in the past)?* —Please choose an option—YesNo

Do you chew tobacco, pan, use gutkha, or supari now (or in the past)?* —Please choose an option—YesNo

Do you drink alcohol?* —Please choose an option—YesNo

What is 2 x 2 ?