Medical Contraindications Assessment Questionnaire Form
Please complete this brief assessment to help us identify any potential contraindications before proceeding. Answer each question as accurately as possible.
Full Name
*
First Name
Last Name
Do you currently have any chronic medical conditions?
*
Yes
No
Unsure
Please rate your current overall health.
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Are you currently taking any prescription medications?
*
Yes
No
Do you have any known allergies?
*
No known allergies
Medications
Foods
Environmental (e.g., pollen, dust)
Other
Have you ever experienced an adverse reaction to a medication or treatment?
*
Yes
No
Not sure
If yes, please briefly describe the reaction.
Do you have any current symptoms such as fever, cough, or shortness of breath?
*
Yes
No
Have you recently undergone any medical procedures or surgeries?
*
Yes
No
Is there anything else you would like us to know regarding your health or medical history?
Submit Assessment
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