Health Questionnaire Health Questionnaire Please enable JavaScript in your browser to complete this form.Health QuestionaireDo you wear a pacemaker or hearing aid? (some of the equipment we use can affect their function)YesNoUnknownIf YES, please provide additional details Do you have any heart/lung/chest problems?YesNoUnknownIf YES, please provide additional detailsHave you had any recent, unexplained weight loss/gain ?YesNoUnknownIf YES, please provide additional details had suffer be Have you had any recent surgery (in the last 5 years)?YesNoUnknownIf YES, please provide additional detailsDo you suffer from high/low blood pressure?YesNoUnknownIf YES, please provide additional detailsHave you ever had a course of steroids or anticoagulants?YesNoUnknownIf YES, please provide additional detailsHave you ever undergone treatment for any type of cancer?YesNoUnknownIf YES, please provide additional details Do you suffer from circulation problems? YesNoUnknownIf YES, please provide additional detailsDo you suffer from asthma or any other allergies?YesNoUnknownIf YES, please provide additional detailsHave you had any recent accidents?YesNoUnknownIf YES, please provide additional detailsDo you suffer from Epilepsy/fits?YesNoUnknownIf YES, please provide additional detailsDo you have Diabetes? YesNoUnknownIf YES, please provide additional detailsAre you or could you be pregnant?YesNoUnknownIf YES, please provide additional detailsAre you taking any medication, whether prescribed or not?YesNoUnknownIf YES, please provide additional detailsDo you suffer from giddiness/fainting or nausea?YesNoUnknownIf YES, please provide additional detailsProvide additional detailsSubmit
