Medical Details/History

Have you had a previous diagnosis of cancer?

Do you have heart issues?

If yes, please check:
AnginaHeart 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:
Diet 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:


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


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: