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1. Has anything changed to your health, in the last couple of months?

2. Are you being treated by a medical specialist?

4. Have you ever had a lifethreathning disease?

5. Are you allergic to anything?

6. Have you ever had a heartattack?

7. Have you ever had palpilations?

8. Are you being treated for high bloodpressure?

9. Do you ever have pain to the chest when you're emotional or exercising?

10. Do you ever have swollen ankels or feet?

11. Are you ever short of breath when you lie down?

12. When exercising, do you ever get short of breath?

13. Do you have a valvularproblem or a artificial heart valve?

14. Do you have a congenital heart defect?

15. Do you have a pacemaker (or ICD)?

16. Are you in the care of the trombosisservice?

17. Have you ever fainted during a dental or medical treatment?

18. Do you ever suffer from hyperventilation?

19. Do you have epilepsy?

20. Have you ever had a cerebral hemorrhage or stroke?

21. Do you have respitoryproblems like asthma, bronchitis or chronic cough?

22. Are you diabetic?

23. Are you anemic?

24. Have you ever had longterm bleeds, after pulling a tooth or after an operation?

25. Do you have (or ever had) hepititas, jaundice or any other liver disease?

26. Do you have a kidneydisease?

27. Do you have chronical bowelproblems?

28. Do you have a condition of the thyroid?

29. Are you reumatic and/or do you have chronic jointproblems??

30. Do you have a contagious disease?

31. Do you suffer from depression?

32. Have you visited a psychologist or psychiatrist, in the last couple of years?

33. Have you ever received radiotion treatment for a tumor to your head or neck?

34. Do you smoke?

35. Do you consume alcohol?

36. Have you, or do you ever use drugs?

37. If you are a woman, are you pregant?

38. Do you have a condition or disease not listed above?

39. Do you currently use medication?