Contact Details
Please tick all that apply ✓ Smoking Number/day: ✓ Alcohol Standard drinks/week: ✓ Recreational drugs ✓ Asthma or persistent cough ✓ Stopping breathing at night/sleep apnoea ✓ Shortness of breath ✓ High blood pressure ✓ Chest pain/angina/heart attack ✓ Pacemaker ✓ Rheumatic fever ✓ Heart murmur/valve problem ✓ Palpitations ✓ Blood/clotting disorders ✓ Blood clots in legs/lungs ✓ Diabetes ✓ Liver problems ✓ Kidney problems ✓ Gastric reflux/hiatus hernia ✓ Epilepsy/fits/nerve problems ✓ Strokes/mini-strokes ✓ Organ transplant ✓ Back injury ✓ Arthritis ✓ Muscle problems ✓ Cancer ✓ Thyroid ✓ Viral diseases (e.g. Hepatitis/HIV) ✓ Anxiety/depression/psychological problems ✓ Neck or jaw injury/limitation ✓ Any capped/crowned/loose teeth ✓ Unable to lie flat on a small pillow
Please list any other allergies:
Females:
Declaration - I have answered the questions listed above as truthfully and accurately as possible.
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