Details

    Medical Details/History

    Have you had a previous diagnosis of cancer?

    Do you have heart issues?

    If yes, please check:
    NoneAnginaHeart attackIrregular pulseFaintingMurmurEndocarditisRheumatic feverPacemaker

    Do you have lung or breathing problems?

    Have you had any neurological problems? (eg. Stroke or seizure)

    Do you have diabetes?

    If yes, which type of current treatment:
    NoneDiet onlyTabletsInsulinPump

    Do you have high blood pressure?

    Have you ever had any blood clots in your legs or lungs?

    Do you have any autoimmune illnesses?

    Do you have a blood or bleeding disorder?

    Are you, or could you be pregnant?

    Are you currently breastfeeding?

    Have you had any of the following:
    Hepatitis BHepatitis CHIV

    Do you smoke or have you ever smoked?

    If yes, specify (approximately):

    Do you drink alcohol?

    Have been exposed to hazardous substances? (eg. asbestos, benzene etc.)

    Your mobility:

    Medications

    Do you take any regular medication? (including herbal, or over the counter medications)

    Allergies

    Do you have any allergies or sensitivities to any medications, latex, food or other:

    Family History

    Do you have any family history of cancer?

    If yes, specify

    Past Surgery

    Enter any previous operations you have had: