Medical History Questionnaire

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? *