Health Declaration Form

Any physical limitations or disabiities:​

Neck / Back aches / Injuries
Joint-related issues
Ligament injuries
Spinal conditions
Spinal conditions
Bowel/Bladder issues
Communicable disease
Chronic pain
Glaucoma / Retinal Detachment / Eye Surgery
Depression / Psychosis
Diabetes
Respiratory conditions
Heart Conditions
High blood pressure
Low blood pressure
Seizures / Epilepsy
Stroke
Bleeding disorders
Hernia
Hospitalization for a psychiatric condition in the past

Have you had any of the following symptoms in the last 14 days?

Fever
Dry cough
Cough with phlegm
Shortness of breath
Sore throat
Runny nose
Body pain
Diarrhea
Chills
Loss of Smell
Loss of taste
Redness of eyes
Any Serious illness in the last three years:
Any Injury in the last three years:
Surgery in the last three years
Psychotherapy, psychological therapy and counseling in the last five years:
H/O Smoking
H/O Drugs:
H/O Alcohol:
For women, Are you currently pregnant or planning for pregnancy?