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Patient details
Medical history questions
Have you been treated for a medical condition, or been admitted to hospital in the last 2 years? *

Do you have, or have you had any of the following medical conditions:

Allergies (e.g. foods/dairy, antibiotics, latex) *
High or low blood pressure *
Heart surgery (e.g. valve replacement, stent, bypass, or pacemaker/Implantable cardiac device (ICD)) *
Bone disease (e.g. osteoporosis) including bone altering medications (oral or infusions) *
Blood thinning medications (e.g. aspirin, warfarin, apixaban, dabigatran, rivaroxaban, clopidogrel, heparin) *
Intellectual/cognitive or physical disability requiring assistance (e.g. dementia, wheelchair, guide/therapy dog) *
A multi-drug resistant infection (e.g. golden staph – MRSA or VRE) *
Treatment for any form of cancer (e.g. surgery, radiotherapy, chemotherapy, immunotherapy) *
Heart disease/disorders (e.g. atrial fibrillation, Rheumatic fever, congenital disorders, heart attack) *
An organ transplant (e.g. kidney, liver, heart, lung, bone marrow) *
Lung disease (e.g. asthma, COPD/emphysema, cystic fibrosis, pneumonia) *
Neurological disorders (e.g. Epilepsy, motor neurone disease, Parkinsons, stroke) *
Blood borne viruses or liver disease (e.g. hepatitis B/C, or HIV) *
Diabetes or kidney disease (e.g. dialysis) *
Mental health issues (e.g. anxiety, depression, bipolar) *
Joint replacement surgery (e.g. hip or knee) *
Are you a current or past smoker? *
Do you have any disease, condition or problem not listed? (e.g. autoimmune disorders) *
Females only: are you pregnant?
Patient declaration

Thank you for your submission

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