2nd Floor, Afriland Towers, 97/101 Broad St, Lagos.
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CHILD 2 DETAILS
CHILD 3 DETAILS
CHILD 4 DETAILS
Chest pain / Angina or heart attack?
PrincipalSpouseChild 1Child 2Child 3Child 4
High blood pressure (hypertension)?
Lung/respiratory condition e.g. asthma, bronchitis, emphysema?
Stomach/bowel disorder e.g. peptic ulcer or diverticulitis or ulcerative colitis?
Urinary or kidney disorder e.g. kidney stones, urine incontinence, recurring urinary tract infections, or any requiring dialysis?
Muscle/bone or joint disorder e.g. bone fractures, osteoporosis, gout, or arthritis?
Diabetes which is controlled by insulin drugs and/or diet?
Epilepsy or seizures?
Depression or schizophrenia or bipolar or other mental health conditions or drug or/and alcohol dependency?
Blood disorder e.g. sickle cell anemia or thalassemias or G6PD?
Disease of the eye or nose or throat lasting longer than six months?
If yes, please give details:
Cancer that has been partially or totally threated?
Have you tested positive for HIV/AIDS?
Have you experienced any of the following unexplained weakness, weight loss, diarrhea, skin lesions or enlarged nymph nodes?
Do you take any prescription medications for periods longer than one month?
If yes, please explain?
Has there been any change in any of your prescription dosage/s?
Have you received any new prescription, investigation or new medical consultation in the last 6 months?
Have you ever been tested or treated for infertility?
Are you pregnant?
When was your last pregnancy?
Any pregnancy complications? Please tick any that pertains to you:
Difficult child delivery
Any history of irregular menstrual cycle?
Any history of gynecologic procedures or surgery?
2nd Floor, Afriland Towers, 97/101 Broad St, Lagos Island, Lagos
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Head Office: 2nd Floor, Afriland Towers, 97/101 Broad Street, Lagos, Nigeria.
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