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Medical questionary

Please take a little moment to answer a few questions:
Date of birth (year)
Gender
Weight lbs kgs
Height
Do you have high blood pressure? Yes No
Are you currently pregnant? Yes No
Have you ever been treated for heart problems or heart rhythm problems? Yes No
Do you take any form of pain killers? Yes No
Do you have any of the following conditions?
Leukemia, Multiple Myeloma, Sickle Cell Disease, Peptic Ulcers, or Retinitis Pigmentosa?		 Yes No
List all current medications, including non-prescription medicines.
List all allergies including medications.
List all medical conditions for which you are currently being treated
Is there anything else in your medical history you deem relevant?
Declaration: I have answered the above questions truthfully and to the best of my knowledge. Yes No

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