| 1. |
Are you currently receiving medical treatment or medical care of any kind? |
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| 2. |
Have you ever suffered, or do you now suffer from: |
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a. Epilepsy, fits or fainting attacks or other mental disturbances |
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b. Tuberculosis, asthma, persistent cough, Pneumonia or any other chest disease |
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c. Rheumatic fever, Hypertension, Circulatory or Heart trouble? |
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d. Indigestion, Chronic or recurrent diarrhea, gastric or duodenal ulcer, jaundice, gall bladder complain? |
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e. Diabetes mellitus, Cancer or tumor of any kind |
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f. Unexplained recurrent or persistent fever? |
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g. Unexplained persistent night sweats? |
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h. Unexplained weight loss |
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Current Weight (in kg)
Height (in M)
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i. Skin disorders |
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j. Nervous disease or nervous breakdown frequent headaches? |
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k. Hepatitis (B) or any sexual transmitted disease (e. Syphilis, gonorrhea) ? |
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| 3. |
Have you received or do you expect to receive any x-rays, electro-cardiogram or any other Hospital or pathological investigation and/or treatment? |
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| 4. |
Have you any physical defect or infirmity or is there any aliment or disease from which you suffered or to which you have a tendency other than stated above? |
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| 5. |
Are there any other circumstances such as engaging in dangerous sports or particular aspects of your occupation, which could be considered hazardous? |
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| 6. |
Are you a smoker? |
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Please state how many cigrettes you smoke a day if yes? |
| 7. |
For Women only: Are you currently pregnant: |
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| 8. |
Did you undergo any dental treatment? |
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If yes, please specify:
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| 9. |
Do you have any additional medical information?
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| Name list of two persons you know to contact |
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