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Medical Screening form – Sure plan & Lipotrim

    Gender?MaleFemale

    Have you watched the Lipotrim Patient Education Video? YesNo

    Have you used the Lipotrim Programme before? YesNo
    _________________________________________________________________
    Now please answer the following as fully as possible:

    Heart Trouble? YesNo

    Chest Pain? YesNo

    High Blood Pressure? YesNo

    Palpitations, faints, blackouts? YesNo

    Asthma, bronchitis, persistent cough? YesNo

    Heartburn, gastric or duodenal ulcer? YesNo

    Attacks of gallstone colic? YesNo

    Stroke? YesNo

    Epilepsy or other neurological illness? YesNo

    Diabetes mellitus? YesNo

    Any disturbance of kidney or bladder? YesNo

    Diarrhoea, colitis, constipation or piles? YesNo

    Thyroid treatment? YesNo

    Severe depression or other nervous disorder? YesNo

    Gout? YesNo

    Allergy to milk? YesNo

    Any other serious illness? YesNo

    Are you taking any medically prescribed drugs, pills, tablets or other medication or having medical treatment in any form? YesNo

    Any disturbance of liver? YesNo

    Have you attended any doctor in the past 12 months? YesNo

    Have you ever had or been recommended to have an operation? YesNo

    Are you? sedentarymoderately activevery active

    ****************** WOMEN ONLY ******************

    Are you pregnant? YesNoN/A

    Are you intending to become pregnant in the next 3 months? YesNoN/A

    Have you given birth in the last 3 months, or miscarried? YesNoN/A

    Are your menstrual periods regular? YesNoN/A

    Are you using a contraceptive cap? YesNoN/A

    I declare that the above answers are true, that I have not omitted any material information and that I authorise the release of the findings of the questionnaire to Waistaway Ltd, Howard Foundation Research Ltd. and the supervising pharmacy. (See T&Cs)?

    You must select Yes to participate.
    YesNo

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