| Are you currently receiving any medical treatment from a doctor, hospital or clinic? |
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| Are you currently taking any prescribed medicines, inhalers, injections or tablets? |
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| Do you carry a medical warning card? |
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| Have you suffered any allergies to medicines, substances or foods? i.e. Penicillin or Latex |
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| Are you, or have you been, under the care of a doctor during the past two years? |
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| Have you ever had any of the following? If so, please tick as appropriate |
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| Have you had any prosthetic surgery? (E.g. Heart Valve or Hip Replacement) |
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| Are you pregnant or possibly pregnant? |
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| Have you ever had your blood refused by the Blood Transfusion Service? |
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| Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches? |
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| How many units of alcohol do you drink a week? |
(One unit is a half a pint of lager, a single measure of spirits or a small glass of wine/aperitif)
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| Do you smoke any tobacco products now, or in the past? |
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| Do you chew tobacco, pan, use gutkha or supari now or in the past? |
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