Taking time to fill out this form truthfully will help in providing the greatest possible experience for you, making it possible to accommodate any special needs or requirements you may have.

Name *
Please include Country and ZIP / Postal Code
Either physical or mental, and please indicate the timespan that you have dealt with the condition(s).
If no, please state the nature of the condition you are suffering and the severity.
If so, please make clear which conditions the drugs have been prescribed for and dosage.
Please indicate approximate use and which drug(s) e.g. Alcohol, Cannabis, Nicotine, Painkillers etc.
Please indicate the severity of the allergy and the substance.
Are you currently pregnant or trying to get pregnant? *
Include time taken travelling to and from work, plus any work you might do at home.
Please include approximate quantity of each beverage.
Total occasions; include 'snacks' as meals.
If you are unsure, be modest in your response.
Include at least 1hr before bed, what time you usually fall asleep and when you wake up in the morning.
Include any regular walking you may have to do, or physical exertion as part of your job.
If you unsure, please be modest in your response.
Please include any useful information not covered above.
I hereby declare to have filled out this form truthfully *
Please check the details of your answers carefully.

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