Please answer all of the following questions truthfully. A false declaration may have serious consequences.
If you answer ‘Yes’ to any of the questions please give full details in the space provided at the end of this section. This should include the date you first developed the condition, details of any tests, investigations and of any treatment you have undergone.
Please include the names and addresses of any specialists you have seen and hospitals you have attended. Please give full details of any medication you are taking.