Medical Screening

Follow-Up

 

 

Click the Box Below Once Follow-up is Resolved

 

 

VITALS

HEALTH SCREENING

1. Are you under the care of a medical doctor at this time OR over the last 6 months?

2. Allergies?

Do you have or have you had any of the following diseases or problems? (If ‘YES’, please give brief explanation)

HAVE YOU HAD ANY JOINT REPLACEMENTS OR ORGAN TRANSPLANTS
HAVE YOU HAD AN ORGAN TRANSPLANT?
DO YOU HAVE ANY ISSUES WITH YOUR KIDNEY, LIVER, PANCREAS, LUNGS (INCLUDING ASTHMA) OR OTHER ORGANS NOT LISTED?
HAVE YOU TESTED POSITIVIE FOR HIV OR HEPITITAS?
DO YOU HAVE ANY AUTOMIMMINE DISEASES, INCLUDING DIABETES, CHRONES, LUPAS, LIME OR OTHER DISEASES?
ARE YOU CURRENTLY TAKING ANY MEDICATIONS?
DO YOU SMOKE OR CONSUME ALCOHOL?
DO YOU USE UNPRESCRIBE DRUGS?