Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating: Certain conditions originating in the perinatal period?

Other Diseases, Accidents, Previous or Future operations you already know about?

Diseases of genitourinary system, kidney diseases and breast disorders?

Does the adherent have any allergy against any Drug, Food or other?

Previous medical/surgical hospitalisations, procedures and operations?

Diseases of the respiratory system ?

Congenital anomalies, hereditary/genetic diseases?

Diseases of the endocrine system, nutritional-, metabolic diseases and immunity disorders, diabetes?

Sexually Transmitted Diseases & AIDS?

Diseases of the musculoskeletal system and connective tissue?

Osteoarticular & Muscular Diseases or Transplants or Disease of the skin and subcutaneous tissue?

Mental / psychiatric disorders?

Diseases of the nervous system and sense organs (ears, eyes, nose) ?

Diseases of the cardiovascular system incl. hypertension?

Diseases of digestive system?

Diseases of blood and blood forming organs?

Neoplasms/Cancer (benign or malignant)?

Any (chronic) disease(s), symptoms and complaints not mentioned above?

Is the adherent following or has ever followed any medical treatment? Did or is he taking medication?

Any Pre-existing disease(s), symptoms and complaints within the last ten years?

Are you currently Pregnant , complications of pregnancy, child birth and the puerperium incl. abortions?