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Do you believe you have the capacity to make decisions about your own healthcare?
YES
NO
Have you been diagnosed with any medical conditions?
YES
NO
Please provide more information, including diagnosis, symptoms and treatment.
Have you ever been diagnosed with a mental health condition?
YES
NO
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
YES
NO
Do you suffer from any allergies?
YES
NO
Do you suffer from any allergies?
YES
NO
What is your blood pressure?
Low (below 90/60)
Normal (between 90/60 and 140/90)
High (above 140/90)
What was the date of your last blood pressure check?
Are you currently using any kind of contraception (pill, ring, patch or other)?
YES
NO
Do you ever have vaginal bleeding even when you are not on your period?
YES
NO
Have you ever been told by a doctor that you have abnormal cholesterol?
YES
NO
Do you have a history of migraines?
YES
NO
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