Name: JW Seagon
Address: 1st Floor, Oilibya Plaza, PO Box: 16658 00620, Muthaiga, Nairobi, Kenya
Telephone: +254 (0) 20 405 0008

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Health Information
Answer the following questions in YES or NO. If answer is yes, please provide details on a separate sheet of paper.
Are you presently in Good Health?*
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Do you have any physical deformity / Handicap or congenital defect/abnormality?*
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During the last five years, have you consulted a doctor or have been advised to undergo any medical investigation or treatment for any medical condition (other than minor cough, cold or flu), or had a surgery or been hospitalized?*
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Health Information (continued)
Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the following condition? Please tick to indicate which condition(s)
Diabetes / Raised Blood sugar, High Blood Pressure/Hypertension, Heart disease, Chest pain, Palpitation, Heart murmur, Heart Attack, Rheumatic Fever, High cholesterol, Disorder of the Heart or blood vessels or undergone heart surgery.*
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Stroke, Epilepsy, Fits, Black-outs, Coma, Paralysis, Multiple Sclerosis, Brain Hermorrhage, Parkinson’s disease, any disease of the Brain, Nervous System, Disease of Kidney, Renal Calculi, Bladder or Urinary Tract, reproductive organs, Disorder of the Eye, Ear, Nose, Throat, Asthma, Tuberculosis, Bronchitis, other lungs and respiratory system.*
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Tumor, Cancer, Leukemia, Hodgkin’s disease, Lymphoma, Cyst, Undergone chemotherapy or radiotherapy, Anaemia, Hemophilia, Thalassaemia or any other disorder of the blood, Gout, Arthritis, Back / Neck / Joint Pain, Slip Disc and other musculoskeletal disorder, any disorder of the digestive system such as Ulcer, Colitis or disease of the liver or pancreas, Goitre/Thyroid/Other Endocrine or gland diseases, depression, Schizophrenia or any Mental Disorders/psychiatric ailment, Skin disease or disorders, Liver or Gall Bladder problems/Jaundice/Hepatitis.*
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Are you currently taking, or have you previously taken, any medication or treatment for a continuous period of more than 10 days for any condition, other than minor coughs, cold, flu, typhoid?*
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Were you ever tested positive for Hepatitis B or C, HIV/AIDS or other sexually transmitted diseases?*
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Do you consume alcohol or tobacco or smoke or have any habit for drugs or narcotics?*
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JWS Protect – Declaration of good health form

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