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Health Statement Form

MRS/MR *

MRS

Name *

First name *

Date of birth *

Adress

Physician

Name

Phone number *

1- Consulted or been treated by any Physician or other Medical Practitioner for any disease pertaining to :

2- DIzzy spells

3- Allergy (latex ? Antibiotics ? Aspirin ?)

Xray, electrocardiogram (EEG), blood analysis or other diagnostic test ?

5- Blood

6- Any accident, injury, surgical operation, hospital confinement, medical advise or examination other than those mentioned above ?

7- Do you smoke ? If yes, number of cigarets/day

8- FOR FEMALE ONLY : Are you pregnant ? (if pregnant, state how many months :

Do you take medecines ?

If yes give details :

I hereby declare and agree that all the statements and answers contained herein are true, complete and correct to the best of my knowledge. SIGNATURE

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