Supplementary [Provisional] Medical Report

+    All questions must be answered    +

Family Name

Given Names

Do you have any physical defect or deformity?

YES NO  

Do you have any congenital abnormality?

YES NO  

Are you in remission from a disease or ailment?

YES NO  

Do you have a speech impediment?

YES NO  

Do you suffer from a chronic disease or disorder?

YES NO  

Do you suffer from Migraine or headaches?

YES NO  

Have you ever been diagnosed with a mental disorder?

YES NO  

Do you need a hearing aid?

YES NO  

Do you wear a prothesis?

YES NO  

Do you have any visible scars, tattoos or birthmarks?

YES NO  

Do you wear spectacles?

YES NO  

If you have answered in the affirmative to any of the preceding questions, please elaborate.

Do you need a special diet?

YES NO  

What is the reason for your diet?

Peanut Allergy Seafood Allergy Coeliac Diabetic Other Medical Reasons Halal Kosher Vegetarian I don't eat Pork No Beef/Bovine Other Religious Personal Choice  

What is your weight?

  Kilo  or    lbs

What is your height?

  Cms  or  Inches

What is the length of your hair?

Bald Shaved Very Short Short Medium Long  

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