General examination

Your information

Full name
Please provide your name as it appears on your birth certificate.
Only letters are accepted.

Date of birth
Please follow the this pattern: Day-Month-Year.
Only numbers and '-' are allowed.

Email address

Nationality

Review of systems

Do you smoke?

If yes, what do you smoke and how many per day?

Do you drink alcohol?

If yes, what do you drink and how much?

Vaccination

Do you have allergies to any medications or other substances?

Do you have any psychological disorders?

Are you currently under the treatment?

Do you have any condition that would require special accommodations?

Current medical condition
If any, list those that you are currently receiving treatment for. Date, month and year

Physical examination

What's your height?

What's your weight?

How is your vision?

Do you have any neck problems?

Do you have any chest/lungs problems?

Do you have any heart problems?

Do you have any abdomen problems?

Do you have any musculoskeletal problems?

Do you have any neurological problems?

Do you have any skin problems?

Do you have any other problems?