Health Questionnaire

HQ | Health Questionnaire

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Full Name *

Company Name *

Date of Birth

If you have been hospitalised for more than 24 hours in the last 3 months, please tell us the reason(s)

Date you were admitted to hospital

Date you were released from hospital

Have you been admitted to hospital more than once in the last 3 months?

Yes

If 'Yes', please provide details

Are you currently attending a Doctor's Surgery or a hospital?

Yes

If 'Yes', please provide details

Are you currently taking any medication or having any treatment from a Doctor or other Medical Practitioner?

Yes

If 'Yes', please provide details

If you are human, leave this field blank.

IntaCapital Swiss SA,
Rue du Rhône 80 - 84,
CH - 1204 Genève,
Switzerland