MEDICAL QUESTIONNAIRE - Arman Bayounsa

Private and Confidential

Please complete this questionnaire. All information will be treated in the strictest of confidence. If you give any information which you know is false, or if you knowingly withhold relevant information, you may be subject to disciplinary action.

Personal Details

Name *

First

Last

Year of Birth

Your GP details

Name of Doctor or medical adviser: *

Practice telephone no:

Tell us about your food allergies

Medical History

Please indicate whether you have ever suffered from, or have previously been diagnosed as having, any of the medical conditions listed below.

Urinary system

Recurrent Cystitis or urethritis
Kidney infection or stones
Prostate or bladder problems
Other kidney or bladder disorder

Glandular System

Thyroid gland disorder
Other glandular disorder

Tropical diseases

Malaria
Other tropical disease

Eyes

Blurred vision
Conjunctivitis
Glaucoma
Other eye problem

Any information you'd like to share

Have you ever failed a medical examination of any kind?

Yes
No

Have you ever consulted or been recommended to consult a specialist?

Yes
No

Have you ever been in hospital?

Yes
No

Are your currently undergoing any treatment or being prescribed drugs by your GP or medical practitioner?

Yes
No

Do you wear glasses for reading/driving?

Yes
No

Do you have difficulty in recognising colours?

Yes
No

Do you have difficulties in hearing?

Yes
No

Have you ever had problems relating to drug or alcohol misuse?

Yes
No

Any information you'd like to share

Declaration

I declare that all information I have given is true and represents an accurate picture of my health. I am not aware of any other condition not referred to elsewhere on this questionnaire. I understand that misrepresentation of facts could lead to disciplinary action being taken against me.

Date *

Signature *