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    [group metres / kgs]

    [/group]

    [group feet / lbs]

    [/group]

    High blood pressure

    high blood

    [group high blood]

    [/group]

    Low blood pressure

    low blood

    [group low blood]

    [/group]

    Diabetes

    diabets

    [group diabets]

    [/group]

    High cholesterol

    cholesterol

    [group cholesterol]

    [/group]

    Heart disease including heart attack, coronary artery disease and chest pain

    heart disease

    [group heart disease]

    [/group]

    Arthritis

    arthritis

    [group arthritis]

    [/group]

    Depression

    depression

    [group depression]

    [/group]

    Anxiety

    anxiety

    [group anxiety]

    [/group]

    Epilepsy

    epilepsy

    [group epilepsy]

    [/group]

    History of seizures or convulsions

    seizures or convulsions

    [group seizures or convulsions]

    [/group]

    Thyroid problems

    thyroid

    [group thyroid]

    [/group]

    Stroke

    stroke

    [group stroke]

    [/group]

    Osteoporosis/Osteopenia

    osteoporosis

    [group osteoporosis]

    [/group]

    Seasonal Allergies

    allergies

    [group allergies]

    [/group]

    Migraines

    migraines

    [group migraines]

    [/group]

    Eye problems

    eye problems

    [group eye problems]

    [/group]

    Hearing problems or Deafness

    deafness

    [group deafness]

    [/group]

    Liver problems, including Hepatitis B or C

    liver problems

    [group liver problems]

    [/group]

    Kidney problems

    kidney problems

    [group kidney problems]

    [/group]

    Cancer

    cancer

    [group cancer]

    [/group]

    Stomach or intestinal conditions

    stomach

    [group stomach]

    [/group]

    Gastric Bypass

    gastric

    [group gastric]

    [/group]

    Irritable Bowel Syndrome

    irritable

    [group irritable]

    [/group]

    Skin conditions or diseases

    skin conditions

    [group skin conditions]

    [/group]

    Special Dietary Requirements (lactose intolerance, vegetarian, other:)

    special dietary

    [group special dietary]

    [/group]

    Asthma

    asthma

    [group asthma]

    [/group]

    Have you had any surgeries in the past 10 years, or major surgeries in your life?

    YesNo

    Do you have any allergies to any foods, medications or other substances such as latex or imaging dye?

    YesNo

    Social Drug Use

    Do you smoke or use tobacco products?

    YesNo

    Cigarettes

    Cigarettes

    [group Cigarettes]

    [/group]

    Cigars

    cigars

    [group cigars]

    [/group]

    Other

    other

    [group other]

    [/group]

    Do you drink alcohol?

    YesNo

    For males only

    Have you had a vasectomy? *

    YesNo

    For females only

    Please check any of the following that apply to you (or None at the bottom of the list)

    Tubes tied

    tube

    [group tube]

    [/group]

    Hysterectomy

    hysterectomy

    [group hysterectomy]

    [/group]

    Removal of ovaries (without a hysterectomy)

    removal of ovaries

    [group removal of ovaries]

    [/group]

    Have you been through the menopause?

    YesNo

    Are you using hormonal replacement theraphy (HRT)?

    YesNo

    If yes, name of treatment

    YesNo

    None

    none

    [group none]


    [/group]

    General Information

    If needed for a study, would you be able to obtain your medical records?

    YesNo

    Emergency contact name

    I have read and agreed to the ICON Data Protection Policy

    agree

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