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Please tick a box if you have ever suffered from any of the following conditions
Heart MurmurYesNo
Heart/Vascular DisorderYesNo
Artificial Heart ValvesYesNo
Rheumatic FeverYesNo
Blood Pressure ProblemsYesNo
DiabetesYesNo
EpilepsyYesNo
AsthmaYesNo
Liver or Kidney DiseaseYesNo
HepatitisYesNo
Excessive BleedingYesNo
Are you a smokerYesNo
Are you Pregnant?N/AYesNo
Recreational Drug UseYesNo
Do you consume wine or sports drinks (ie Gatorade) on a regular basis?YesNo
Are you vaccinated against Covid-19?YesNo
Allergies(eg: Penicillin, Latex)YesNo
Current Medication
Joint Replacement? YesNo
Do you suffer from OsteoporosisYesNo
Are you taking any drugs for Osteoporosis or cancer related treatment ie: bisphosphonates? YesNo
History of recent/past surgeries
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