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MEDICAL QUESTIONNAIRE

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DOWNLOAD OUR HEALTH QUESTIONNAIRE

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Please indicate if you have or have had any of the following conditions:
Any known intolerance to cold
Reynauds Disease (if so extra gloves and socks may be required)
Undergoing current Cancer treatment
Diabetes
Hypothyroidism
Sever Hypertension (BP > 180/100)
Infection
Fever
Symptomatic Lung Disorders
Severe Anaemia
Acute or recent myocardial infarction
Unstable angina pectoris
Arrythmia
Symtomatic cardiovascular disease
Cardiac Pacemaker
Peripheral Arterial Occlusive disease
Croglonulinemia (Blood clotting disorder associated with extreme cold temperatures)
Cold urticaria (Hives on the skin associated with extreme cold temperatures)
Venous Thrombosis
Pregnancy
Acute or recent cerebrovascular accident
Uncontrolled seizures
Bleeding disorders
Claustrophobia
Declaration:

Thanks for submitting!

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