Patient medical history Have you ever had:Heart Disease*YesNoHigh Blood Pressure*YesNoRheumatic Fever*YesNoDiabetes/ inherited Disease*YesNoAllergies*YesNoAsthma, Chest Disease*YesNoJoint Replacement*YesNoBlood Disease/Bleeder etc*YesNoStomach Ulcers*YesNoSnoring problems*YesNoInfectious Diseases e.g. HIV, AIDS, Hepatitis A, B or C or any other illnesses of significance we should know of?*Are you on any medications e.g. Cortisone, Warfarin?*Females: Are you pregnant?Additional notes and commentsName* First Patient mobile number*Email* Date of Birth* Date Format: DD dash MM dash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code CommentsThis field is for validation purposes and should be left unchanged.