Health History Questionnaire

Have you smoked in the last 12 months? *

Have you ever completed a Bachelors or Masters Degree? (Note : This doesn’t have to be relevant to your current occupation) *

Do you take part in, or have definite plans to take part in any sports, recreations or pastimes? (e.g. Football, Diving, Sky Diving, Motorcycle racing, car racing, boat racing, martial arts, rock climbing, sailing, cycling, mountain biking, horse riding. If you are unsure, please select 'yes'.) *

Do you have any booked overseas travel in the next 2 years? *

Have you tested positive Coronavirus (Covid-19)? *

Are you currently in quarantine or enforced self-isolation for Coronavirus (Covid-19) due to possible infection? *

Raised blood pressure or cholesterol, Diabetes or raised blood sugar? *

Stress, anxiety, depression, insomnia or any other mental health illness? *

Have you ever had a Mental Health Plan from your GP for free counselling session? *

Anemia, thrombosis or any other blood condition? *

Asthma, sleep apnoea or any other medical affecting your lungs or breathing? *

Asthma, sleep apnoea or any other medical affecting your lungs or breathing? *

Crohn’s disease, colitis, IBS or any other medical condition affecting your stomach, bowel or digestive system? *

Kidney stones, urinary infection or any other medical condition affecting your kidneys, bladder or urine (or prostate for males)? *

Kidney stones, urinary infection or any other medical condition affecting your kidneys, bladder or urine (or prostate for males)? *

Any medical condition affecting your liver or pancreas? *

Tinnitus, labrynthitis or any other medical condition affecting your ears or balance? *

Impaired vision, optic neuritis or any other medical condition affecting your eyes? *

Persistent headaches, migraines, numbness, pins and needles, muscle weakness or any other neurological symptoms? *

Growths, lumps, moles or cysts? *

Cancer, leukemia, Hodgkin’s disease or any other tumor? *

Cancer, leukemia, Hodgkin’s disease or any other tumor? *

Heart attack, irregular heart beat or any other heart condition or heart surgery? *

A stroke, TIA, brain hemorrhage or damage or surgery to your brain? *

Multiple sclerosis, epilepsy or any other neurological condition? *

An abnormal mammogram or abnormal pap smear? (females only) *

A positive test for HIV/AIDS, hepatitis screening, or genetic test of any kind? *

Any back, neck, joint surgery or any other musculoskeletal conditions requiring physiotherapy or chiropractic visits? *

Any illness or symptoms that required medical treatment in the last five years? *

Heart attack, angina, stroke or Diabetes *

Bowel cancer or familial bowel polyps *

Cancer of the breast or ovaries *

Any other type of cancer *

Muscular dystrophy, Huntington’s disease, motor neurone disease or Polycystic Kidney disease *

Cardiomyopathy *

Parkinson’s disease, Alzheimer’s disease or multiple sclerosis *

Any other hereditary disease or condition *