Customer Medical
Questionnaire

Please complete this medical questionnaire before your appointmant.

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Name *

First

Last

Date of Birth *

Mobile Number *

Email *

Appointment Date *

Height *

Weight *

Waist Size *

Occupation *

Have you had any organs removed? *

Yes
No

If yes, please give details.

Do you have any Pre-existing medical conditions? (e.g Diabetes, High Blood Pressure) *

Yes
No

If yes, please give details.

Do you take any regular medication? *

Yes
No

If yes, please give details.

Do you consume alcohol? *

Yes
No

If yes, how much per week?

Are you a smoker? *

Yes
No

If yes, how many per day?

Do you have a Pacemaker or ICD device fitted? *

Yes
No

Do you have Life Insurance? *

Yes
No

Do you have either Private Medical or Critical Illness Cover? *

Yes
No

I declare that all the information filled in is accurate to the best of my knowledge. *

Yes

I am happy to receive a follow up call after my appointment from Peak Health & Edward Bond regarding ongoing support, related health cover, additional health advice and periodic check-ups. *

Yes

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30 Bloomsbury Street

London, WC1B

United Kingdom

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We are proud to be one of the few companies in London that provide an affordable Full Body Health screening service.

Customer Medical Questionnaire

Customer Medical
Questionnaire