JubiAgent

Medical History

1. Are you now in good health?	Yes No
2. Have you consulted any doctor or medical facility either as an inpatient or outpatient in the last 3 years?	Yes No
3. Have you within the past six (6) months undergone any medical tests?	Yes No
4. Have you ever met with serious injury?	Yes No
5. Are you currently taking any medication regularly or as needed?	Yes No
6. Have you ever had, been tested for, received treatment or counselling from a medical professional for or been told you have: (Tick appropriate item and give details where applicable)
a. Dizziness, fainting, convulsions, epilepsy, paralysis, stroke or severe headaches?	Yes No
b. Depression, anxiety, Alzheimer’s disease, mental or nervous disorder?	Yes No
c. Shortness of breath, bronchitis, emphysema, asthma, pleurisy, pneumonia, tuberculosis or persistent cough?	Yes No
d. Chest pain, angina, palpitations, irregular heartbeat, high blood pressure, heart attack, congestive heart failure or coronary artery disease?	Yes No
e. Heart murmur, heart valve disorder, oedema or disorder of the heart or blood vessels?	Yes No
f. Ulcers, intestinal bleeding, colitis, ulcerative colitis, Crohn’s disease, jaundice, hernia, diarrhoea,hepatitis or any disorder of the stomach, intestines, spleen, liver, or rectum	Yes No
g. Diabetes, high blood sugar or sugar in your urine?	Yes No
h. Blood or protein in your urine, any disorder of the kidneys, bladder, prostate or urinary system?	Yes No
i. Venereal disease or any disorder of the reproductive system?	Yes No
j. Thyroid, thymus, pituitary or lymph gland disorder?	Yes No
k. Cancer, sarcoidosis, tumor or any abnormal growth?	Yes No
l. Back pain, muscular dystrophy or any disorder of the muscles, bones or joints?	Yes No
m. Multiple Sclerosis, Parkinsons disease or any disorder of the brain or spinal cord?	Yes No
n. Haemophilia, Sickle Cell anemia, anemia or any disorder of the blood?	Yes No
o. Any disease not mentioned above?	Yes No
p. Have you
i. ever had or been advised to have a blood test for AIDS or an AIDS-related condition?	Yes No
ii. received a blood transfusion within the last 5 years?	Yes No
7. Part (c) applicable to (females only) Are you now pregnant?	Yes No
If yes, how far advanced?

Details of yes answers above

Question No.	Details including: dates, details of treatment, medical institution where treated and treating doctor