ࡱ>  0לbjbj pM %%%9998q$9'.""""#'%'%'%'%'%'%'(t+Z%'9%"!"""%' ^'_&_&_&"8%#'_&"#'_&_&& & 9#Z&'t'0'&,$~,&,%&0""_&"""""%'%'_&"""'"""",""""""""" :   Medical Enquiry Form To be completed by the applicant DO NOT EMAIL THIS FORM Please complete and return to Occupational Health, Perrigo, Wrafton, Braunton, Devon EX33 2DL All information is confidential and will be viewed by Occupational Health Department only. Please ensure you sign the declaration on the last page before returning the form. Personal Details Surname : Mrs/Miss/Mr/Ms/Other : Forenames : Age : Date of birth : . Next of Kin : ... Job applied for : Home Address : . . Telephone no :  GP Details : Name : Dr .. Health Centre : .Details of previous 3 jobs : Dates Occupation .. .. ..  Any known allergies? q Yes (please state) & & & & & & & & & & & & & & & & & q No Date of last Tetanus injection & & & & & & & & & & & & & & & & &  Are you Dyslexic? Yes / No  Hobbies, leisure activities, other paid work : & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & & ..& & & & & & &  Do you suffer from, or have you ever received treatment for any of the following:YesNoDetails e.g. frequency, no of years, reoccurrenceWhen was the last time it caused a problem?Heart or circulatory illness including raised blood pressure and/or varicose veinsGastrointestinal symptoms, disorders or diseases e.g. stomach ulcersFrequent sore throats Tonsillitis/Throat infections/TonsillectomyBronchitis, T.B., Pleurisy, Pneumonia or any lung condition EczemaAsthma, hay fever, any other respiratory symptoms/disordersGenito-urinary symptoms, disorders or diseases e.g. bladder, kidney problems, cystitisNeurological symptoms e.g. epilepsy, fainting, or giddinessEndocrine (glandular) symptoms, disorders or diseases (including diabetes, Thyroid)Psychiatric illness or nervous troubles, depression or anxiety/stress even if mildSevere, frequent or prolonged headaches/migraines.Eye disease or problems e.g. glaucoma, partial blindness etc.Do you wear corrective lenses e.g. glasses, contact lensesEar troubles or diseases/hard of hearing. If so, do you wear a hearing aid?Any broken bones or problems with your hands, arms, shoulders, legs or feet which affect movement or normal use YesNoDetails e.g. frequency, no of years, reoccurrenceWhen was the last time it caused a problem?Back conditions, pain, slipped disc, muscular or any other symptomsSkin problems/diseases e.g. eczema, dermatitis, psoriasis etc.Anemia/blood disordersAny menstrual (period) problems Sleep disturbances/problems/lethargyIs there a family history of Asthma/Eczema?Have you ever had any industrial or occupational disease or accident?Are you receiving any treatment/medication, special diets or injections from your GP, Specialist Consultant, Osteopath, Chiropractor etc.How many days lost from work over the last 12 months. Give dates, reason and length of absenceAre you attending a hospital or are you on a waiting list for any hospital treatmentHave you had any operations? Do you smoke? If yes age started, how many cigarettes a day?How many units of Alcohol do you consume a week? (1 pint = 2 units, 1 short = 1 unit, 1 glass of wine = 1 unit) Have you ever left, or been denied, a job on health grounds?Have you ever used or are you presently using an addictive substance?Please enter any additional information in this box. If there is insufficient room please continue on another sheet.  YesNoMore information e.g. severity, left or right, when it first occurred, how long it lasted, treatment, reoccurrencesAre you still suffering from it? If not, when was the last time you had problems with it? Knees/hips/pelvic problems Broken bones in arms/hands Any dislocations Arthritis affecting your arms Shoulder problems Tennis elbow / Golfers elbow Persistent discomfort in forearm Pain, tingling or discomfort in wrists Carpal tunnel syndrome Tenosynovitis Pain, discomfort or tingling in hands or fingers Sciatica, rheumatism, arthritis Back/ neck pain or ache OtherTo your knowledge, are you colour blind? Yes / NoAre you left or right handed? Please read this statement carefully before signing.I declare that all the foregoing statements are true to the best of my knowledge. I accept that in the event of my being employed and it subsequently being shown that medical information has not been disclosed by me, or has been misleading or false, that the Company may terminate my employment. I understand that I may be required to attend for consultation and physical examination. I understand that although this form will be treated in medical confidence, further medical information may be required from my doctor if this is considered necessary.SignedDate For Occupational Health onlyBlood Pressure UrinalysisWeight ;Rp ^ q r  * b c x   TU_ö߭ߢ߭߭߭ߘߘ߭uukkkkh.NHOJQJh.5CJNHOJQJh.5CJOJQJh.5NHOJQJh.CJOJQJh.5CJ OJQJh.5OJQJh&}5>*CJOJQJh.5>*CJOJQJh.h.5>*OJQJ\h.OJQJh. h.5jh.5UmHnHu*;R_ ` q r s {{$If\kd$$Ifl4%%04 lalf4$If$a$gd&}$a$gd.$a$   * + , H I ^ _ t u \kd$$Ifl4%%04 lalf4$If   3 4 J K a b c lkd$$Ifl0b%b04 lal$Ifc x y 2 4 X f h & ( lkd$$Ifl0b%b04 lal$If ( * , $If^kd<$$Ifl4%%04 lalf4 ] xx$If^kd$$Ifl4%%04 lalf4]^_cfo$If$If\kdR$$Ifl4'J(04 laf4 YQQEQQ x$If`x$Ifkd$$Iflra&' j N04 la efghiYQQQQQx$Ifkd$$Iflra&' j N04 laijYQKQQQQ$Ifx$Ifkd$$Iflra&' j N04 laYQQQQQx$Ifkdl$$Iflra&' j N04 la6789:YQQQQQx$Ifkd@$$Iflra&' j N04 la:;YQQQQQx$Ifkd$$Iflra&' j N04 laYQQQQQx$Ifkd$$Iflra&' j N04 la,-./0YQQQQQx$Ifkd $$Iflra&' j N04 la%&hi   =>opuv,-NO-.xy !֎hc5CJOJQJ"jh.OJQJUmHnHu&jh.CJOJQJUmHnHuh.CJOJQJh.5CJNHOJQJh.5CJOJQJh.5OJQJh.h.NHOJQJh.OJQJ701YQQQQQx$Ifkd $$Iflra&' j N04 laYQQQQQx$Ifkdd $$Iflra&' j N04 laYQQQQQx$Ifkd8 $$Iflra&' j N04 la?@ABCYQQQQQx$Ifkd $$Iflra&' j N04 laCDYQQQQQx$Ifkd $$Iflra&' j N04 la YQQQQQx$Ifkd$$Iflra&' j N04 la    .<YWQKKKKK$If$Ifkd$$Iflra&' j N04 la<IuvSKKKKKx$Ifkd\$$Iflra&' j N04 la$IfYQQQQQx$Ifkd>$$Iflra&' j N04 laYQQQQQx$Ifkd$$Iflra&' j N04 la@ABCDYQQQQQx$Ifkd$$Iflra&' j N04 laDEjklmnYQQQQQx$Ifkd$$Iflra&' j N04 lanoYQQQQQx$Ifkd$$Iflra&' j N04 laYQQQQQx$Ifkdb$$Iflra&' j N04 lauvwxyYQQQQQx$Ifkd6$$Iflra&' j N04 layzYQKQQQQ$Ifx$Ifkd $$Iflra&' j N04 la34567YQQQQQx$Ifkd$$Iflra&' j N04 la78UVWXYZYQKQQQQ$Ifx$Ifkd$$Iflra&' j N04 laZ[YQQQQQx$Ifkd$$Iflra&' j N04 laYQKQKQQQ$Ifx$IfkdZ$$Iflra&' j N04 laRSTUVQkd.$$Iflra&' j N04 lax$IfVWYQQQQQx$Ifkd$$Iflra&' j N04 laYSSSSSM$If$Ifkd$$Iflra&' j N04 la !%($If$If[kd$$Ifl'J(04 laYQQQQQQx$IfkdT$$Iflra&' j N04 la:;QRuv!"56lmIOP89W`|}~h&}h]Wjh]WUh.h.5>*OJQJUjh.OJQJU"jh.OJQJUmHnHuh.NHOJQJh.CJOJQJh.OJQJh.CJOJQJ956789YQQQQQQx$Ifkd6$$Iflra&' j N04 la9:;LMNOPYQQQQQQx$Ifkd $$Iflra&' j N04 laPQRpqrstYQQQQQQx$Ifkd $$Iflra&' j N04 latuvYQQQQQQx$Ifkd!$$Iflra&' j N04 laYQQQQQQx$Ifkd"$$Iflra&' j N04 laYQQQQQQx$IfkdZ#$$Iflra&' j N04 laYQQQQQQx$Ifkd.$$$Iflra&' j N04 la YQQQQQQx$Ifkd%$$Iflra&' j N04 la !"01234YQQQQQQx$Ifkd%$$Iflra&' j N04 la456ghijkYQQQQQQx$Ifkd&$$Iflra&' j N04 laklmYQQQQQQx$Ifkd~'$$Iflra&' j N04 laYQQQQQQx$IfkdR($$Iflra&' j N04 laYQDQQQQ  9r x$Ifx$Ifkd&)$$Iflra&' j N04 laYQQx$Ifkd)$$Iflra&' j N04 lax$Ifokd*$$Ifl40' A04 laf4IJ+[kd+$$IflQ''04 la$Ifokdf+$$Ifl40' A04 laf4Jrvv x$If\kd,$$Ifl4Q''04 laf4 & Fexx$If^e` & Fx$If$Iflkd-$$Ifl0Q'04 la x$IfYkd-$$IflQ''04 laVW`abcdefx$IflkdF.$$Ifl0Q'04 la Colour Vision Test ____________________ Close Vision Test ___________________ COMMENTS Referrals:      PAGE  PAGE 4 OH/mydocs/med enq form/updated sept05 Assessed: fgrstuvwxyz{$If$If[kd.$$Ifl Q''04 la {|}h`h&`#$x[kdf/$$Ifl~Q''04 laɜʜԜלh.5CJOJQJh]Whc0JmHnHuh. h.0Jjh.0JUǜȜɜʜԜ՜֜לx$a$$h`ha$7 0PP&P . A!"S#S$%77 F/A~TmIpUn ^יJFIFC     C   q" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?S((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((9&E(Գ*$ݠ?OImeH"K_W|^}uG'_a'I!dgL埳m~Ϟ"uIuJ?&G!?60O-~RˤuY5%Fi⯄,̷ u* Psk|G|7wCukޛҏNp3_tH,ѣ0.\[8ȯ2|&cUSqۻ?Cc'.?K !~ 'Q 5|#5ZO>]]C ]^(UYqSiWΣooglsK(Br~U ߒ ~~Ɵ|i!E>AǗY]eooewea5.~x+]w^ރ*c W-iQgRSM^IͧGʽy ,Á|aop% %Q8$|סx$kV'̫ҫ?R>@O)>=֫r[ X?W>^i I]b/[\W'(ך.3bENz>LotmVܸ6pz+o.b!huwNuS3M : OwPĖ׈̣Tξ[S<)o^ I>WCĐtukS|' MԼ?Rhi-Aϯ2|k5ĭkær"nЎq+a*`KE:OgV6gUQ_wNkH/j%/n^u$N (ad^e|cO5K&L aڻYبfp$WY41Zzv/vg;R4"O#q.j?z<pqJѭoQAvWˍF3`s- xm_k`ss_O.`=)*gS4(3x Q FA|YznTHt}=s?u߇.ޥWN,YHqW.R-H~v5to/~fo4g?T}xQE<|G_V$|g]4 JI C ?z$dQo0b޾Ď+[[g#Qi扵5U ,KV q_?d|(n^=..XG|x| tJiu]lඛbx]ʹ B9Il'z'KǞ)|AZQsp8=>ꗱ9TAfb:^p']N8Flv3UtNCsy^ >u6S_)R8["ϑr}_WuC̫%Q2!S7h?T|Ջ@kgk6?g~=j(J ~u:_ؙ_JvxO 9xZnI{:ğn':4SV5&$Xv"FxWORodz(PZ?n<^㴟arR4Vz19z7|Q{ Ln=_z9]/[O>9i+Toƭo],38F@!a/|/zDgOاtyߧo¼{Ěv+Rw*bBxG"ʫٿ)*Yh1?7.튓EkڿfMt=UigE0^WʎLL퐂r;NygxPOƩJh pŚdX,.X4՝|u(5#@|gq-mh[o#I=ਗ਼ [Vq|כG=C_ +&)/5hk㛍R8rFq1url4jcw-z 18F|OO0<bۛ? #SP?g?,F jo!i3[;KkSi^-ѯ[NܦWTdl1wrTBz]cc֮p]R*PvyT?PG ׍ FPmirg=kl_W.(|k֛h\$y,QŘvƿWiZʩ~ћk-;)Y]G  OZՏ  MWz7-v%I ^OK9$NK_褷>$ KITn7CRFBx|8[; 2=*.dTaw}k꿰r(/ʯK}kJ{&7|iz"xLB4R7S)_{PӠi.._]$bd;&7n?ur{S_:Wo*W1$ BkzW_o!~^}/TeW P)Ri&!p{t&׆ ]jcmN, 퓊(0(WV:vǏ+Ÿ9PiO5W,'Ӽ!GjIdYܯ d~+_#ωωCm$ H݊I  fh`I ⺰\=BT1M\{Sq-ি$BH@M~"JЈ+ W:>١ս93+Go7cnI:|1윱;8 ^׿|GbT#1c~lL f:6TM5B:WYW}zRx3b 08|VX%F_r?Og_◎4 xCOkyd.2+z>!|9[B h!7I͐"O, <q? SD<4oHB?RE~~Oq%KԱ&2aѧWZ ӫOZ3;ƿ&Zbu23Jk;^M5B|qMJ{~u]CsLT]'4ee*U;kכ%fѪ (aEPEPEPEPEPE^ _լ{YIo&63OҚNN +fZ'սjn P.[d6h9֞ʦ+"W|Ŏ[ $1ǾH? zп5?ƾxTU2^^YSK),HFe_imW;vG妡gR$Y$;_`~̿UՓ4T,\@=  ]iv՜I*yp>o&q}/wt񦃧å([Sxdzy_ufU08l'{#=s;><9n6Zm[D_ :ZZV  n8=q\!>:z^ ,~ ͖>$߈b-Hm!1\d}~ S*rYfۺ:Scq"+) 2kkߌ!kʋ]!B-+3'=4^iAjݏm%v~uC>=?Ŀw5-Z'WZl=zBI?΍SQծ%L36srOrZM̋H 0H¿ip|UZr# *;Q[K2'*̒{Egr| ?hVZݍv%;X(0Ilƺ([XdjMji")cةtGi57fZʩ6ӭ nߧE_Ԋ`[I~Wf^q}?iIiOB4+sk/&r< Wi,XҿL0.IU^,Cdυw_0h)?ԋA̫G1Rɡ|+Фجsߤ'* Ek<˿_>(Ь Ky#TcbOJO^2ֵJbO3$1eW]y˿oxT#2 2:0)ɾR]Ϣ0=(xOm~.l}#Vo%X`+Iwnq^4o +qgcu$(ԢR-?4;,B>9«?.#<@ dos_cH rm3|gǫj1K#i6lvHT@XWEj5i:u&M&Ʌec^pO wemmPB8bP0@/aco kE.nLt}HQR1 }3cqJN1hk/ TS>gV&X,y摈UFOkĞ(,7N#\=}a޺} {}vI%<ī9+K0e} nϦ3^ e0X񴞋̫)%N->vn\cq$Bp3_-mb[b7ǺNmU' < xLJ@ۉ 9_J< 3uKJcGuoT|{_l6m[?|fGqhT`0?1cZ4|w1<瞵G{~4) H$C9v$p8=s yfF򵭈Z~07|{FmT *i–]彣qOVճ'ߧh>:ΣPmF ]6zZ>I-ۍNEXd"QO|S_Fto?ֿ!ҴӋNGӧNT]~/iĚ&ce.f `q:G;lJ懖9,.z_I)ak~0'Tk9l5'!O*<qIW0C])/9X1&} փebB鷨Ywg>/ :Gtc8an׵}OWo4пd2=J~*]|pxW>LP!!9k|4kϡSSn՞gf;ɀW\?bρ%Z.oJ@68XG5󥵷uVUH8#޼c?c'<]@bu_^#C3^}N%Vz{VPYkk * WHcy$*3pI߷tSz5AFGzq_Уh_*Ceggk Qƽ@=~-KZUgӂ&)hM((((((('3~OℚqxsÛFS#mۥ~|`|Q|;tImomḻrn$ ܃ڿ9'_Tfte$3IcuU1SIYeSO_#㘧LI DV`UAvd ㇈f嬠oFw`gÿK W_#e7BG2yymN8渿wV_X|>kc?$?_cS$I^/Y5.=? R^Ҳۿs /Q(o:1=r8 _>5ơ%ե_sM(-W_?=~|>>t#°M9s^d=^DZ巉t8"@_E#&Jݗc|c;Sn~ l 1:ޟ;ib-E Әػu9z/ \OOBMH^?!^YiFUWG.&]ӋOĽ:z܊LY˱jwxK  H#9]t9IrkѾ/OM6: B n[No*k$wrIӌ,s,'~ύ¤5;ž7FPi~hQDVq,1yw?S_Pg[mX{)ԚڳxEa{m67B{{˨ˢ:y1W{jI^3ЭJYOxÚ8u1_)f/ \4'۷rNG[$}G}WGZoy >iRÕYl  WEq-{frI,O^UH ZvfuFFX&r|;Ҽ=BXioBd{rXSJRznoD~8!|eˇwm8_7[Q YD#e򫊱K]3ylg4O#&&~aIϭ{/~'s9A"u(%U=zdr_!X*yQemRBTzi~];ɤ|*]bңKm8?O 2^8fk K^0uٚPif͐=x S׵6 ̾TH 6~>[]7hED% ga'HM_k%J ^O-\N.[7xڧjKOkݡ¼P2I{? ֌G_t7 x44k3`8z~,=o^ͬ+/h>T'F 31u$_?5kYLcc)9Q5|jgyYi_m6_yGc;Q & 6 bu,$9!/xO_Z$m}<2Y^CYlKHP"?wl$ {/(Ѭpx&がֿv+/);M'4Եa4Q!A~u8#b0IkL䥱[5)0;|ǟ˃^9>1oEMZt-LlKp# 5v9y.yW'ǿ<_F?~|H8-hgF8ʓOX¬h`OO<|<%%}O?W~:tm& tmgaO,s랕nqr]33IӮ?A;`2dU+m.2x`c prAk9wۧcR֥ >k.}'Vka~4 ooA9{z_wKf%xiw8w5e^~qē] :M-0zOl:?SzDƭBM+k2=+ʯflTrSᡗacN%,LK&/y:K[D6zsJ0 s03kۋ~7jb]D>i=[}DCm7JwY~g3=4ҡۖNFq^]\ΦGRuܷkp^Fȅ\)rxԿ'eûژup9Ku?l ^M BakOw\Nd21߇4MNtmtt "<\U:Po]GW- KI/.V!# ǥ~||c>"|Э_iPo(O  9knOi0ɪYiZ~ж?|Mx3Úw>Kd%#U]8ɯ#i %(.M۱׌Iԓ~GƓ4s2p^+sn"xHޒ% :0$BK*p 󞤚 b /_- )][w>WfX`pxT)JUgpOgO|(.+FDH qؑ_D¥ ă5n}ek[H\g5pbMG18b uO9r7WGp`ոGҏ/'UʧqZDXQ@UQ6li>I5;BEY"HE :m)[R3y*Xl:/p%ݗbFw`p/C>.^Z ]4mʝp3Mʾ?i-# #Hխ+ M|o_[Ե7-OUGz]ؙܝ/E~:UiQ,,1FUFһe(8=p(((((((_\Y7]Ӳ/ⰝlWmRM;;7) %6ŔG5'G%}3ž2uêTմR{Y}|y k -/&x"G=Ll}\_ß؃]nS🍴"d#̍&(U|k˳pƵH˖_>>y|prF #}o^Ӽ7K[Q Ԣ4_5Onc>7MJ,bkY]2J>6ʟdz/_5{R?y6u#վr΋W:=_J%FP}fB: u|;~^!%vX/R.H2ޯiO&ķ8WWqx䷾vw3ky 5F㞜&ޭ@ eqPG^FEz\Go +q"gcu$6~*h:72\[*:Ps_A\*u߇7> _ዋk}=F9N3_-#Rjugt+/z-?F|O^moڂ@$c)ـ8l;88xǮ+žoLm, X!F01ׯ,e~zDՆ Sx?is\+rP8+/7ՕJ 79nŠ+7İW:$0@m-"4lp:׎ݎ U |D_O,dlnnGǚuDV,׃W:ޣy}w kZi$ery5\!&m B< ֿ[v <*-=ugסZnwnc}l`91H3p}X~|#{LGc[` g>s[?,n"UoNJQEy_SϋSѾ3:d_UYAֺEp-Leq2}k*СLG¿>>#j d|dP7oWLڍ,.qW\1^5–&1[ s# B`*jguEiUVMAy},P׊{AKKHdOhpe巭Y wxNj47,G8#U.wUqrgw#m^?lߍgY%XR5 p}z;1|h$ &Ч&zr9R`{τmYVV\N8bC#tU$¿kkŝX+ d''ZOt]Z-PQ rdG'~/5 -L}9FC_ 'il-Ty ~xIb$GovrF;_?tk/B湾*xxw:x\$*sճQVGWG'`]#àt81HRJ܌瓞߅~jLfǑsq!Y^ŋ3I9U!Z::#v,qwz .F56]^jrqc|L6:iaȌs#L Yƶgߧ#μUl .}{zǃ k/h";X,jιPxfܟ|CռSjڗi^gc~L~c%j%; !e(kU?Ws 1_ X(x[OBTVr=I&L<[ w-DžIT暲G)Vd`pdnfAj[ c!v~_~VqjhzϔM"D$I~*HtxW4r6:`S)YHTݮθpVI Eڨڙ ݄!v{0xǷT,@F|tS6$1?%E7$+|AKOh4cTSu1Ŧ't<ӭBo|q?* Murp71VKxTQyP.e2įσ~|$>+x:Ԩ|?"O's`Oچ~_𿅋[2Ǧc%8?}௄> i&LvAܱ<:T> x[\Ye}_q58U9I~-;wzpңM; y e?/eCo2Jq '\,!'> UYoyWڮ#=yGUܺy9La]'?ufs{ ]k<dzmK%Vn~_^14%cZ_GEƆ*:YO6}StVBgVH͞I?ֿEYx&: B٠^;2e5@c>aOZĘ(S~ɹ>5a~?{+j!|SGmk(q8ʵG=pT⢂(c@((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((($$Ifl!vh5%#v%:V l405%4alf4$$Ifl!vh5%#v%:V l405%4alf4$$Ifl!vh5b5#vb#v:V l05b54al$$Ifl!vh5b5#vb#v:V l05b54al$$Ifl!vh5%#v%:V l405%4alf4$$Ifl!vh5%#v%:V l405%4alf4$$If!vh5J(#vJ(:V l405J(/ 4f4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N/ 4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N/ 4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N/ 4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N/ 4$$If!vh5J(#vJ(:V l05J(/ 4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N/ 4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 555j 5N#v #v#v#vj #vN:V l05 555j 5N4$$If!vh5 5A#v #vA:V l405 5A4f4$$If!vh5 5A#v #vA:V l405 5A4f4$$If!vh5'#v':V l05'/ 4$$If!vh5'#v':V l405'/ 4f4$$If!vh55#v#v:V l055/ 4$$If!vh5'#v':V l05'/ 4$$If!vh55#v#v:V l055/ 4~$$If!vh5'#v':V l 05'4~$$If!vh5'#v':V l~05'4^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_H mH nH sH tH <`< NormalCJ_HmH sH tH J@J  Heading 1$$x@&a$5CJ >@>  Heading 2$$@&a$CJ@@@  Heading 3$x@&5>@>  Heading 4 $x@&5>*DD  Heading 5$$x@&a$5>*J@J  Heading 6$$@&a$6CJOJQJDA`D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List 4@4 0Header  9r 4 @4 Footer  9r .)@.  Page Number>/!> &}0 Header CharCJ_HmH sH H2H &}0 Balloon TextCJOJQJ^JaJZ/AZ &}0Balloon Text Char CJOJQJ^J_HaJmH sH PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] (9 ( LLLOל9Q c ( ]i:0C <Dny7ZV9Pt 4kJf{ל !"#$%&'()*+,-./012345678:;<=>?@ABCDEFGHIJKLMOPR "O!!  ;:/Xb$s$Bi[ /R$~TmIpUn ^י7A9 0e0e     @ 5% 8c8c     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||@  9(  zB & 6 D?#" ?zB ' 6 D?#" ?zB ( 6 D?#" ?zB ) 6 D?#" ?zB * 6 D?#" ?zB , 6 D?#" ?zB - 6 D?#" ? 8 c >APerrigo logo#" ?\ 9 # 9#" ? B S  ?H0(  +,-(8 NT9 t,Pt-PPt*0%t)`t(P&t' P&t&0tO| )s1:7> ! ( 8 ? PV)33333333333333333333`r,bT 8 n rP~ *5`lQ$)$ hh^h`.$&}]Wc.J?_@4yyQ(x@x x@x8@UnknownG* Times New Roman5Symbol3. * Arial5. *aTahomaA BCambria Math"1e lfr03F  % %#0d2HP $P.2!xx7C:\My Documents\Form Templates\Medical Enquiry form.dotEPlease complete and return in enclosed envelope with application formWrafton Laboratoriesehowells Oh+'0 @ T`    HPlease complete and return in enclosed envelope with application formWrafton LaboratoriesMedical Enquiry form ehowells4Microsoft Office Word@e@aI@Fk@A ՜.+,0@ hp  "WRAFTON LABORATORIES%  FPlease complete and return in enclosed envelope with application form Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrsuvwxyz{|}~Root Entry Fy Data t/1Table,WordDocument pSummaryInformation(DocumentSummaryInformation8MsoDataStoref  ZYIET2BWIKQ==2f  Item  PropertiesUCompObj y   F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q