Confidential Health Form
Impact DTS Winter 2023
Applicant Name:
First Name
Last Name
DTS Dates:
Blood Type:
Height:
Weight:
Explain any recent weight changes:
List all important past surgeries, illnesses, injuries, or handicaps and please explain the circumstances.
Have you ever had a severe emotional breakdown or been diagnosed with any form of mental illness (i.e. anxiety and/or depression)? Please describe.
Have you ever struggled with feelings of wanting to harm yourself? Have you ever acted on these feelings?
Are you under a doctor's care for mental health conditions? If so, please describe the duration and frequency.
Have you ever used drugs (including recreational drugs) for reasons other than medical purposes? If yes, please explain.
Please list your current medications.
Rows
Medication
Prescribed For
Date Prescribed
How Often Taken
1
2
3
4
5
Do any of these medications have negative side effects? If so, please describe.
Have you ever had or do you have any of the following conditions?
Rows
Yes
No
Skin Condition
Jaundice
High Blood Pressure
Low Blood Pressure
Intestinal Trouble
Recurrent Diarrhea
Migraines
Head Injury
Sexually Transmitted Disease
Fainting Spells
Neurological Disorder
Fatigue
Paralysis
Heart Condition
Rheumatism/Arthritis
Shortness of Breath
Stomach Ulcer
Gall Bladder Problems
Eye Trouble
Ear Trouble
Diabetes
Kidney Disease
Epilepsy
Anemia
Hepatitis A
Hepatitis B
Insomnia
Back Problems
Hay Fever
Dislocation of Joints
Broken Bones
Asthma
Tumor/Cancer
If you answered yes to any conditions above, please describe:
Have you had any of the following communicable diseases?
Rows
Yes
No
Chicken Pox
Scarlet Fever
Pertussis
Tuberculosis
Measles
Mumps
Do you have any allergies (i.e. peanut butter, bees, cats)?
Do you carry medication or an EpiPen with you for your allergy?
Please upload a copy of your immunization record.
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Are you vaccinated against COVID-19? *This is not required, however, we do need a record of your vaccination status.
1st Dose
2nd Dose
Booster
Not Vaccinated
Please describe any other medical history or conditions that may be relevant.
*For Females Only:
Rows
Yes
No
Currently Pregnant
Past Pregnancies
Problems with Menstrual Cycle
Optional Comments:
Signature:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
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