Regarding yourself have you suffered any major illness/operations, e.g. cancer, TBC, heart problems, diabetes, etc.
Do you suffer from / have you suffered from high blood pressure?
Do you have any allergies?
Have you ever suffered in the past any infectious diseases? (e.g. hemopathia A, B, salmolosis, typhus)
Are you under any instructions/prescriptions from your doctor?
Please state ages(s) of children, and any problems while giving birth. Cesarian etc.
If you are undergoing a Lap Band or BIB procedure, please continue to fill out the next section on this form, otherwise, please click here, and click the "send now" button at the bottom of the page.
