Do you have, or have you suffered from, any of the underlisted conditions?
Chest pain / Angina or heart attack?
High blood pressure (hypertension)?
Lung/respiratory condition e.g. asthma, bronchitis, emphysema?
Stomach / bowel disorder e.g. peptic ulcer or diverculitis or ulcerative colitis?
Urinary or kidney disorder e.g. kidney stones, urine incontinence, recurrent urinary tract infections or any requiring dialysis?
Muscle / bone or joint discorder 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 drug or / and alcohol dependency?
Blood disorder e.g. sickle cell anemia or thalassemias or G6PD deficiencies or leukemia?
Disease of the eye or nose or throat lasting longer than six months?
Cancer that has been partially treated?
Have you suffered from any condition requiring surgery in the last six months?
Have you ever had or advised to be tested for HIV?
Have you suffered any of the following unexplained weakness or weight loss or diarrhea or skin lesions or enlarged lymph nodes?
Are you currently taking any prescription medications for over 1 month?
Had any prescription changed or reduced or stopped or increased?
Have you received any new prescription or investigation or new medical consultation in the past 6 months?
Have you ever been tested or treated for infertility?