Health Contraindications Survey
Please complete this survey to help us identify any health conditions that may affect your participation or care. Answer all questions as accurately as possible.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following pre-existing medical conditions? (Select all that apply)
*
Heart disease
High blood pressure
Diabetes
Asthma or other respiratory conditions
Epilepsy or seizures
None of the above
Other
Please indicate if you have any allergies (food, medications, environmental):
*
Are you currently taking any prescription or over-the-counter medications?
*
Yes
No
If yes, please list all current medications:
Have you experienced any of the following in the past year? (Select all that apply)
*
Hospitalization
Surgery
Serious injury
None of the above
Please rate your overall current health status:
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Family Medical History: Please indicate if any immediate family members have had the following conditions.
*
Rows
Heart disease
Diabetes
Cancer
Other (please specify)
Yes
1
2
3
4
No
5
6
7
8
Unknown
9
10
11
12
Lifestyle Factors (Select all that apply):
*
Current smoker
Former smoker
Alcohol consumption
Regular exercise
None of the above
Is there anything else about your health that we should be aware of?
Submit Survey
Should be Empty: