Medical History Questionaire
Full Name
*
First Name
Last Name
Email
*
Confirmation Email
confirm email
Date of Birth
*
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Month
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Day
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Year
*
Male
Female
Weight
*
Height
*
Personal Health History
In the last 10 years, have you been treated for or diagnosed with:
1. High Blood Pressure, heart attack, chest pain, heart murmur, irregular heartbeat, stroke or any other disease of disorder of the heart or blood vessels?
*
Yes
No
2. Cancer, tumor, cyst or growth?
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Yes
No
3. Asthma, bronchitis, emphysema, tuberculosis or any other disease or disorder of the lungs or respiratory system?
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Yes
No
4. Seizure, paralysis, headache, multiple sclerosis or any other disease or disorder of the brain or nervous system?
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Yes
No
5. Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder?
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Yes
No
6. Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gallbladder, pancreas or digestive tract?
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Yes
No
7. Diabetes, borderline diabetes, sugar in the urine, thyroid disorder or any other disease or disorder of the glandular system?
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Yes
No
8. Kidney stones, nephritis, blood or protein in the urine, HIV, sexually transmitted disease, prostate disorder, breast disorder or any other disease or disorder of the urinary or reproductive system?
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Yes
No
9. Any disease or disorder of the bones, joints or muscles?
*
Yes
No
If answered YES to any of the above questions, please provide details
10. Are you currently taking any medication?
*
Yes
No
If so, please list medications here:
11. Have your parents or siblings died from diabetes, cancer, stroke or heart disease?
*
Yes
No
If answered YES to the above question, please provide details:
Activities & Health Habits within the last 5 years
12. Have you used tobacco in any form (including gum/patch)
*
Yes
No
If YES, when last used:
13. Engaged in any of the following activities: scuba/skin diving, pilot, organized motor vehicle racing, skydiving, hang gliding, mountain climbing or rodeo?
*
Yes
No
If answered YES to any of the above questions, please provide details
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