Weight Loss Medical Details

PERSONAL DETAILS

First Name *

Last Name *

Email *

MEDICAL HISTORY - Diseases

Do you have high blood pressure? *

Take Medication

Occasionally

Rarely

Never

Have you ever had any breathing difficulties including asthma? *

Often

Occasionally

Rarely

Never

Have you every been diagnosed with Heart Disease or had a Heart Attack? *

Yes

No

Have you ever tested positive for Hepatitis? *

Yes

No

Have you ever tested positive for HIV? *

Yes

No

If you have answered yes to any of these questions please provide additional details.

Have you ever been diagnosed as diabetic? *

Yes

No

Included Type 1 and Type 2 diabeties.

If yes, how long have you been a diabetic?

If yes, what are you doing to control your diabetes?

Any other medical conditions or disorders not listed?

Detail thecondition, how long your have had this condition and the treatment you are taking.

MEDICAL HISTORY - Surgery

Have you had surgery before? *

Yes

No

Please provide details of previous surgeries. Include the procedure, dates etc

HEALTH HISTORY

List all medications you are currently taking. Include frequency, dose and date started. *

If you are not currently taking any medical type 'none'.

Are you allergic to any medications? *

Yes

No

If allergic to any medications please list medications and allergic reactions.

Are you allergic to Latex *

Yes

No

Do you suffer from indigestion or reflux? *

Yes

No

Food Allergy *

Yes

No

If allergic to any food please provide details of foods and reactions.

Do you Smoke or Vape *

Smoke

Vape

Both (Smoke & Vape)

No Smoker

Have you ever had keloid scarring? *

Yes

No

Please provide details of ALL vitamins or food/nutritional supplements you are currently taking.