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Vitality Create
We develop a personalised program specific to your own requirements
Please complete the following information and one of our Health Consultants will be in touch
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Name
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Your answer
Date Of Birth
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Your answer
Sex
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Male
Female
Nationality
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Your answer
Country of residence
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Your answer
Mobile telephone number
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Your answer
Email address
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Your answer
What do you want to achieve with this program?
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Your answer
When was your most recent medical examination?
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Your answer
What were the results?
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Your answer
Medical History. Please select the following conditions you experience:
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Has your doctor ever said your blood pressure was too high?
Do you ever have pain in your chest or heart?
Are you often bothered by a thumping of the heart?
Does your heart often race?
Do you ever notice extra heartbeats or skipped beats?
Are your ankles often badly swollen?
Do cold hands or feet trouble you even in hot weather?
Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?
Do you suffer from frequent cramps in your legs?
Do you often have difficulty breathing?
Do you get out of breath long before anyone else?
Do you sometimes get out of breath when sitting still or sleeping?
Has a doctor ever told you your cholesterol level was high?
Has a doctor ever told you that you have an abdominal aortic aneurysm?
Has a doctor ever told you that you have critical aortic stenosis?
None of the above, please complete below
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Please inform us of any other medical conditions you would like to treat:
Your answer
Thank you
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