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Medical Form

Name and Surname

E-mail

Weight

Phone

Height

Age

Do you suffer from any chronic illnesses? If yes, please write them below.

Have you undergone any surgeries? If yes, please write them below with their dates.

Do you take any drugs regularly or have you lately stopped using any of them? (including aspirin and non-prescription) If yes, please list them below.

Do you use any herbal supplements or vitamins? If yes, please list them below.

Do you smoke cigarettes? If you do, for how long have you been smoking and how many cigarettes do you smoke each day? Please write it below.

Do you drink alcohol? If yes, how often? Please write below.

I hereby authorize Arcelia Tourism Travel Agency to disclose the personal data I have provided to medical professionals and/or healthcare institutions.

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Medical Form

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