Health form

Your name(Obligatoriskt)
Today's date(Obligatoriskt)
Do you smoke?(Obligatoriskt)
Do you have high blood pressure?(Obligatoriskt)
Do you take any medication? (For example blood thinning medicine)(Obligatoriskt)
Are you allergic to any medication? (for example antibiotics)(Obligatoriskt)
Do you have a blood infection? (for example Hepatitis B/C or HIV)(Obligatoriskt)
Do you have any of the following diseases?