Male Patients Form 10

MALE FEMALE

YES NO

YES NO

Your doctor or specialist Self diagnosis If other, please specify:

Make you weak on one side Give you visual loss or double vision Make you more uncoordinated or clumsy than normal Give you ringing in the ears or trouble hearing Make you unable to control parts of your body or speech None of the above If other, please specify:

I understand

NO If YES, please specify:

No If YES, please specify:

You have high cholesterol A parent, brother or sister developed heart disease before they were 60 You smoke more than 10 cigarettes a day or use nicotine replacement therapies You are diabetic None of the above If other, please specify:

NO If YES, please specify:

NO If YES, please specify:

I understand and have answered honestly and truthfully

I am happy to continue with my request

Yes I confirm this treatment is for my personal use only.