Spiritus8® Medical Screening Form
This information is protected health information (PHI) and will be kept strictly confidential in accordance with HIPAA.
Do you have cardiovascular disease, angina, or a history of heart attack?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have a psychiatric diagnosis?
*
Yes
No
Have you had surgery in the past 6 months?
*
Yes
No
Do you have past or recent physical injuries (fractures, dislocations, or spinal injuries)?
*
Yes
No
Do you have an infectious or communicable disease?
*
Yes
No
Do you have glaucoma?
*
Yes
No
Have you experienced retinal detachment?
*
Yes
No
Do you have epilepsy?
*
Yes
No
Do you have osteoporosis?
*
Yes
No
Do you have asthma?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Have you ever been hospitalized for a serious illness?
*
Yes
No
Have you ever been psychiatrically hospitalized?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
Is there anything else about your physical or emotional health that we should know to best support you?
*
Submit
Should be Empty: