Name and Surname

Male or Female Male or FemaleMaleFemale

Date of Birth Y M D

ID Number

Medical Aid

Medical Aid Number

Contact Number

Email Address

Emergency Contact Name

Emergency Contact Number

Are you currently healthy Are you currently healthyYesNo

Do or did you suffer from one of the following conditions Do or did you suffer from one of the following conditions Heart diseases Do you currently use medication for the heart Serious hypertension Epilepsy Serious asthma Kidney failure Recently performed surgery Migraine Auto-immune diseases such as rheumatism MS Crohn diabetes asthma Are you currently pregnant or do you wish to become pregnant Are you allergic to a certain substance Non of the above

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