Full Name

Email Address

Contact Number

Gender

Age

Your Medical History

Are you currently in a flare? Are you currently in a flare? Yes No

Do you have any allergies? Do you have any allergies? Yes No

Are you a smoker? Are you a smoker? Yes No

Any History of Cancer? Any History of Cancer? Yes No

Cardiovascular Disorders Cardiovascular Disorders High Blood Pressure Angina Heart Attack High Cholesterol Bypass / Stent / Pacemaker

Metabolism Metabolism Type I Diabetes Type II Diabetes Thyroid Disorder

Bladder/Kidney Disorders Bladder/Kidney Disorders Kidney Stones Kidney Failure without Dialysis Kidney Failure with Dialysis

Pulmonary Disorders Pulmonary Disorders Bronchitis Interstitial Lung Disease Previous Pulmonary TB Asthma COPD

Musculoskeletal Disorders Musculoskeletal Disorders Osteoarthritis Osteoporosis Back Pain Gout Rheumatoid Arthritis Ankylosing Spondylitis

Digestive System Disorders Digestive System Disorders IBS Constipation Peptic Ulcer Heart Burn

Central Nervous System Disorders Central Nervous System Disorders Stroke Migraine Insomnia Epilepsy Parkinson's Disease Multiple Sclerosis Alzheimer's Disease

Dermatological Dermatological Eczema Dermatitis Psoriasis Shingles

Psychiatry Psychiatry Depression Anxiety OCD Eating Disorders

Liver Liver Hepatitis B Hepatitis C Liver Cirrhosis Liver Transplant

Are you willing to travel to Milnerton, Cape Town, to participate in the study? Are you willing to travel to Milnerton, Cape Town, to participate in the study? Yes No

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