Book your consultation

Book Now Mobile

Medical History Questionnaire

Medical History
press Enter
1. Have you ever been diagnosed with Tuberculosis (TB)?
Have you ever had to take treatment for Tuberculosis (TB)?
2. Have you ever been in close contact at work or at home with a person known to have Tuberculosis (TB)?
3. Have you ever been admitted to hospital and/or received medical treatment for an extended period for any reason (including for a major operation or treatment of a psychiatric illness)?
4. Do you suffer, or have you ever suffered, from mental health problems?
5. Have you ever been told you are HIV positive?
6. Have you ever had a positive Hepatitis B or Hepatitis C blood test?
7. Do you have or have you had cancer in the last 5 years?
8. Do you have high blood sugar / diabetes?
9. Do you have heart problems, including high blood pressure or a heart condition that you were born with?
10. Do you have a blood condition?
11. Do you have bladder or kidney problems?
12. Do you have a physical or intellectual disability that makes it difficult for you to function independently (for example, to move around or learn) or be able to work full-time?
13. Are you, or have you ever been, addicted to drugs or alcohol?
14. Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements)?
15. Are you pregnant?
Use Shift+Tab to go back
Scroll to Top