Medical History Questionnaire Medical History Startpress Enter Full Name * Email * Mobile * 1. Have you ever been diagnosed with Tuberculosis (TB)? * Yes No Have you ever had to take treatment for Tuberculosis (TB)? * Yes No 2. Have you ever been in close contact at work or at home with a person known to have Tuberculosis (TB)? * Yes No 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)? * Yes No 4. Do you suffer, or have you ever suffered, from mental health problems? * Yes No 5. Have you ever been told you are HIV positive? * Yes No 6. Have you ever had a positive Hepatitis B or Hepatitis C blood test? * Yes No 7. Do you have or have you had cancer in the last 5 years? * Yes No 8. Do you have high blood sugar / diabetes? * Yes No 9. Do you have heart problems, including high blood pressure or a heart condition that you were born with? * Yes No 10. Do you have a blood condition? * Yes No 11. Do you have bladder or kidney problems? * Yes No 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? * Yes No 13. Are you, or have you ever been, addicted to drugs or alcohol? * Yes No 14. Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements)? * Yes No List of prescribed pills or medication * = 15. Are you pregnant? * Yes No Signature Clear If you are human, leave this field blank. ContinueSubmit Use Shift+Tab to go back