Are you in good health at the present time to the best of your knowledge?

Yes

No

Are you under a doctor's care at the present time?

Yes

No

Any allergies to any medications?

Yes

No

History of High Blood Pressure?

Yes

No

History of Glaucoma?

Yes

No

History of Swelling Feet?

Yes

No

History of Diabetes?

Yes

No

History of Heart Attack or Chest Pain?

Yes

No

History of Chronic Headaches?

Yes

No

Serious Injuries?

Yes

No

Any Surgeries?

Yes

No

Check All That Apply

Polio

Kidneys

Rheumatic Fever

Ulcers

Anemia

Psychiatric Illness

Lung Disease

Scarlet Fever

Bleeding Disorder

Gout

Heart Valve Disorder

Alcohol Abuse

Arthritis

Liver Disease

Nervous Breakdown

Thyroid Disease

Heart Disease

Blood Transfusion

Cancer

Osteoporosis

Drug Abuse

Eating Disorder

Gallbladder Disorder

Has any blood relative ever had any of the following: *

Glaucoma

Asthma

Epilepsy

High Blood Pressure

Kidney Disease

Diabetes

Tuberculosis

Psychiatric Disorder

Heart Disease/Stroke

None