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MEDICAL AUTOCERTIFICATION
Gender ( Male / Female ) M F
Weight
Height
Are you taking painkillers or NSAIDs? ✓ X
Do you have high blood pressure? ✓ X
Do you currently suffer or have you previously suffered from heart problems or cardiac arrhythmia? ✓ X
Are you pregnant or breastfeeding? ✓ X
Do you have these conditions? Leukemia, multiple myeloma, sickle cell anemia, peptic ulcers or retinitis pigmentosa ✓ X
Indicate the medications you are currently taking.
Make a list of all the medications you are taking.
He declared that I answered all the questions honestly.
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