Telephone:              Mobile:      

Names of Doctor:    Telephone:

Occupation:           

Medical History:     

Age:                           Height:   Weight:  

Medication:           

Medical Conditions: Please tick those conditions below which you suffer from:

Diabetes Epilepsy Asthma Broken Capillaries Allergies Major Surgery
Metal Pins/Plates Skin Complaints Spinal Problems Heart Problems 
High Blood Pressure Sinus Problems

Finally, please click here to confirm that the information given is correct