{"text":"[ -dUL UZERRU 14701 ALKBURNE LRLTEIALIVE ItL\u2018?le\u2018l&UZbSl \nTHE AIRBORNE INITIATIVE \nCratenging \u00a7 Tencling benavoyr \nMEDICAL QUESTIONNAIRE \nNaME_DPAND Trsavisgn \nThe foliowing information will be treated in the strictest confidence. \nPlease answer the following questions. If the answer is YES then plesse provide full details. \nHave you at any time suffered form the foRowing conditions: \nGENITO-URINARY \nKidney stoncs Y \nEpilepsy YE \nFainting atacks YE. \nPara yuis YE \n_] Sevcre headaches \nPain on urination YE \nSugaralbumin unne YE \nChest pain Anzeria \nHeart disorder Anxiery RESPIRATORY 1 \nHigh blood Blood disorder Chronic cough \npressure Cancer Plewssy \nPalpitations VNG Depressior Pncumonia \nRheumatic fever YE @ Oiabctes Sinusitis \nTuberculosis \nGeners! Debility \nInsomnia \nSkin Disorder \nSENSES \nColour Blingness \nEar Dusorder \nEye disorder \nThroat disorder \nJaundice \nPepde Uleer \nRectal bleeding \nArthrity \nBackache \nBack Injury \nDis\u00a2 disorder \nGout \nJounvTendon disorder \nRheurnatsm \nIf you have nnswered YES to sy of the questions sbave, please give full details betow \nWhen was the last time you consulted your doctor? A _Yead Ao | Date: \nRenson: B g (\ufb01usrmmw d@rvaity Lo ) \nAre you currently taking any medication or do you antici ate doing 30 in the near future? \nI YES, plemse give detath: \nHow many days heve you been gick in the lagl 12 mooths? \nDo you expect to require me off work for any medical veason within the aext 12 months? YESNO \nIf YES, please give detalts: ~ 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