*1.Hospital Number(Required.)

*2.Is your general health is getting worse ?(Required.)

Yes

No

*3.Do you have any of the following;(Required.)

Pain in back or ribs.

Swelling in your legs or tummy.

Any bones breaking easily.

Are you easily bruising or bleeding.

Any numbness or tingling in feet, hands or legs.

None of the above

*4.Are you suffering with extreme tiredness ?(Required.)

Yes

No

*5.Are you having infections often that do not clear easily?(Required.)

Yes

No

*6.Do you feel out of breath all the time?(Required.)

Yes

No

*7.Have you lost weight for no reason ?(Required.)

Yes

No