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| Name & Surname: |
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| Do you smoke?: |
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| Do you suffer from vertigo?: |
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| Are you pregnant?: |
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| Are you allergic to wheat?: |
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| Are you vegetarian?: |
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| Do you have any special dietary requirements?: |
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| Weight: |
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| Height: |
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| Blood group: |
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| Do you suffer from any blood disease or coagulation problems? |
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| Which? |
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| Do you have any respiratory problems? |
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| Which? |
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| Are you allergic to anything? |
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| Allergic to |
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| Any other comments |
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| Typical treatment |
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| Are you diabetic? |
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| Do you self administrate insulin? |
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| Have you had an anti-tetanus jab in the last 10 years? |
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| Last jab |
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| Are you epileptic? |
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| Do you have a high blood pressure? |
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| Have you had any heart problems? |
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| Do you suffer from a contagious disease? |
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| Have you ever had surgery? |
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| Date and type of surgery |
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| Have you ever had appendicitis? |
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| Have you ever broken a limb or had back problems? |
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| Which? |
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| Have you ever had muscular lesions? |
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| Which? |
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| Do you use a pacemaker or prothesis? |
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| Any comments |
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| Have you had a medical check up in the last few months? |
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| Was any comment made which could be of importance? |
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| Are you currently receiving any kind of medical treatment? |
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| Any comments |
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| Are you currently taking any kind of medication? |
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| If so, what and how often. |
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| Do you have travel insurance? |
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| Which? |
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| Do you have medical insurance? |
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| Which? |
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| Can you swim? |
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| How would you describe your state of health? |
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| Emergency contact |
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| Name and surname |
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| Address |
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| City |
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| Province/State |
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| Country |
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| Telephone/Fax |
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| Alternative phone number |
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| Email |
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| Relationship to you |
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Note: Diabetics or Allergy prone people who are insulin dependant must bring their own medication with an extra dose and be able to self administrate. |
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