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Address Line 1:

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Do You Suffer Or Have You Ever Suffered From Heart Disease Yes No

Have You Ever Had A Heart Attack Yes No

Do You Suffer Or Have You Ever Suffered From Strokes Yes No

Do You Suffer Or Have You Ever Suffered From Cancer Yes No

Do You Suffer Or Have You Ever Suffered From Diabetes Yes No

Do You Suffer Or Have You Ever Suffered From Asthma Yes No

Do You Suffer Or Have You Ever Suffered From High Blood Pressure Yes No

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If You Have Answered Yes To Any Of The Above Please Give Details Including Dates:

Please List Any Operations You Have Had And When:

Please List Any Serious Injuries Or Illnesses You Have Had And When:

Are You On Any Medication Yes No

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I Understand That These Records Will Be Kept On File And Used In The Case Of An Emergency. If There Is Any Changes Please Redo This Form So We Can Update Your Records

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Thornton Hall Hotel & Spa,
Neston Road,
Thornton Hough,
Wirral, CH63 1JF

0151 336 3938 | [email protected]

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