General Prescreening Questionnaire
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
What is your race?
Please Select
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Some Other Race
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
What medical conditions are you diagnosed with? Also list surgeries. List them all below with the start and end dates if applicable:
Are you currently taking any medication?
Yes
No
Please list them all below, include the dosage, start and end date if applicable:
Do you have any medication allergies?
Yes
No
Not Sure
Please list the allergies with the start date.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Submit
Should be Empty: