Preliminary Screening

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Do you smoke or use any form of tobacco or nicotine products?

YESNO

5

Have you had anything major happen with your health like cancer, stroke, heart problems or anything similar?

YESNO

6

Do you have any minor health concerns like high blood pressure, diabetes, or rheumatoid arthritis or anything similar?

YESNO

7

Do you have any respiratory concerns like asthma, sleep apnea, or COPD?

YESNO

8

Do you suffer from any of the following: depression, bipolar, anxiety, PTSD, schizophrenia or anything similar?

YESNO

9

Have you had any surgeries or hospitalizations in the past 10 years?

YESNO

10

Have you received Disability or worker's compensation in the past 5 years?

YESNO

11

Height and Weight

12

Age

13

Have you ever had a suspended driver's license, reckless driving, DUI or anything similar?

YESNO

14

Have you ever been convicted of a felony or misdemeanor?

YESNO

15

Choose a time for me to follow up with you.