Have you been infected with HIV (Human Immunodeficiency Virus), been diagnosed as having HIV antibodies or suffered from an AIDS related condition?

Have you or your spouse received medical advice, testing or treatment in connection with sexually transmitted disease or HIV infection or suffered from prolonged weight loss, Yes No Yes No diarrhea, enlarged glands or unusual skin lesion or been advised to abstain from donating blood?

Diabetes, thyroid disorders or any other hormone disorder?

Ear discharge, impaired sight, hearing, or speech or any other disorder of ear, eye, nose or throat?

Asthma, pneumonia, tuberculosis, emphysema, coughing up blood, persistent cough, or any other disorder of the chest or lungs?

High blood pressure, palpitations, chest pain, raised cholesterol, heart attack, or any other disorder of the heart or blood vessels?

Hepatitis (including Hepatitis B carrier), liver disorder, gall bladder disorder, ulcer, bleeding from the stomach or bowel, hemorrhoids or any other disorder of the digestive tract?

Kidney or bladder disorder, urine abnormality or genital organ disorder?

Cancer, tumor, cyst or growth of any kind?

Anemia, hemophilia, leukemia or any other blood disorder?

Back or neck complaint, arthritis, gout, physical disability or other disorder of the bones joints or muscles?

Any illness that has caused you to be absent from work for a continuous period of 7 days or more?

Stroke, epilepsy, fits recurrent headache, paralysis, faints or any other disease or disorder of the brain, spinal cord or nerves?

Depression, anxiety, schizophrenia or any other mental or nervous disorder?

Have you had any other illness, injury, operation or abnormality not mentioned under any question above which is recurrent or has symptoms persisting for more than 7 days?

Do you have any symptoms or condition for which you intend to attend a doctor in the future

Are you, or have you been in close with anyone who have been quarantined or who have been diagnose with novel coronavirus (SARS-CoV-2/COVID-19) ? if yes, please provide details.

Are you , or have you ever been serving a notice of quarantine in any form imposed by local health authorities or goverment or airport authority for possible exposure to novel coronavirus (SARS-CoV-2/COVID-19) ? if yes please provide more details like location, dates, quarantine period.

Have you ever advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus (SARSCoV-2/COVID-19) ? Or, are you awaiting the result of a test which have already been submitted for novel coronavirus (SARC-CoV-2/COVID-19)?

Have you experienced any of the following symptoms within last 14 days?

Do you have any physical defects, impairment, deformities and/or any condition affecting mobility, sight and/or hearing?

In the past 10 years have you been diagnosed, treated or sought treatment or advice for cancer (including N skin cancer or ulcerated moles), tumor or leukemia?

In the past 5 years have you had any diagnostic tests e.g. Mammogram, X-ray, ultrasound, CT scan, biopsy, N blood or urine test for any lump, cyst, tumor, chronic lesions or growths of any kind?

Have 2 or more immediate family members (natural parents & siblings) ever been diagnosed below age 60 N with cancer, tumor or leukemia?

Has your father been diagnosed with bowel or colon cancer, below age 60?

Has your mother been diagnosed with breast cancer, below age 60?