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HEALTH DETAILS |
Self Spouse/Partner
Are you currently in good health? Yes q No q Yes q No q
If not, please give details _______________ __________________
Do you smoke? Yes q No q Yes q No
If no, have you smoked in the last
12 months? Yes q No q Yes q No q
Please give details of your
Height and weight _______(ht)_____(wt) _____(ht)_____(wt)
Do you follow any hazardous pursuits?
(e.g. skiing, hang gliding, diving) Yes q No q Yes q No q
If so, please give details ___________________ _________________
___________________ _________________
___________________ _________________