Supplemental Health Questionnaire Step 1 of 5 20% Name(Required) First Last Date(Required) MM slash DD slash YYYY Please provide information about the primary care doctor you last consulted within the last five years.Primary Care Doctor(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Date Last Seen(Required) MM slash DD slash YYYY Reason(Required)SelectRoutine PhysicalCheck-UpOtherPlease explain...(Required)What treatment or medication was given or recommended?(Required)Was your primary care doctor the last physician seen?(Required)SelectYesNoDoctor Last Seen(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Date Last Seen(Required) MM slash DD slash YYYY Reason(Required)What treatment or medication was given or recommended?(Required) Height (Feet)(Required)Height (Inches)(Required)Weight (lbs)(Required)Have you lost more than 10 lbs in the past year?(Required)SelectYesNoReason for change in weight:(Required)SelectDietExerciseIllnessPregnancyOtherPlease explain...(Required)How much weight have you lost in the past year? (lbs)(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for any cancer or tumor?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for high blood pressure, heart murmur, irregular heartbeat, palpitations, heart attack, coronary artery disease, chest pain, or any other disease or disorder of the heart, blood vessels or circulatory system?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for high blood sugar, high cholesterol, diabetes, thyroid disorder or any disease or disorder of the blood (except HIV), skin, glands or endocrine system?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for disease or disorder of the kidney, bladder or urinary systems (including blood or protein in the urine)?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for any disease or disorder of the prostate, breasts, reproductive system (including infertility) or genital organs or complications of pregnancy?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for Crohn’s disease or colitis, blood in stool, hepatitis or any disease or disorder of the liver, colon, pancreas, spleen, stomach, intestines, esophagus, rectum, gall bladder or hernia or surgery for weight loss?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for arthritis, chronic pain, auto-immune or connective tissue disorder, multiple sclerosis, Parkinson’s disease or tremor?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for any disease, disorder or condition of the back, neck, spine/spinal cord, joints, limbs or bones?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for asthma, emphysema, chronic obstructive pulmonary disease, shortness of breath, disease or disorder of the lungs or respiratory system, allergies or any sleep disorder including sleep apnea?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for seizure disorder, stroke, transient ischemic attack (TIA), memory loss, Alzheimer’s disease, dizziness, headache or disease or disorder of the brain?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for any disease or disorder of the eyes, vision, ears, hearing, nose or throat?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for anxiety, depression, stress, attention deficit disorder (ADD), post-traumatic stress disorder (PTSD) or any other mental, nervous, eating or emotional disorder?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you been diagnosed with, treated for, tested positive for, been given medical advice by a member of the medical profession or received a consultation or counseling for chronic fatigue syndrome, fibromyalgia, neuritis, neuralgia, narcolepsy, insomnia, restless leg syndrome, Epstein Barr virus, Lyme Disease, muscle weakness or any disease or disorder of the muscles, nerves or nervous system?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Have you had an amputation of any kind or any physical deformity, handicap or impairment that has been diagnosed by a member of the medical profession?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Within the past 10 years, have you received any speech, physical or occupational therapy?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Within the past 10 years, have you tested positive, been diagnosed by or received treatment from a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV)?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Are you currently taking prescription medication or have been prescribed any medication within the past 6 months that was not already disclosed?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required) Are you currently taking non-prescription medication or supplements?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Describe your complete use of tobacco or tobacco products below. This includes, but is not limited to: cigarettes, cigars, pipes, chewing tobacco, snuff, hookah, nicotine gum, nicotine patch and electronic delivery devices. If N/A select "I have never used tobacco products"(Required) Cigarettes Cigars Pipes Chewing Tobacco Other I have never used tobacco products Please explain...(Required)Please list each product you use, the quantity, frequency, and date last used.(Required)Describe your complete use of alcohol below. This includes, but is not limited to: beer, wine and liquor. "I have never used alcohol"(Required) Beer Wine Liquor Other I have never used alcohol Please explain...(Required)Please list each product you use, the quantity, frequency, and date last used.(Required)Describe your use of marijuana, in any form, in the last 5 years below.(Required)SelectI have not used marijuana in the last 5 yearsRecreational/SocialMedicinalReason for Use:(Required)Prescribing Doctor’s Name:(Required)Date Last Used(Required) MM slash DD slash YYYY Frequency(Required)In the past 10 years, have you used stimulants, cocaine, heroin, morphine, hallucinogens, methamphetamines, narcotics, opioids or any other illicit drug or controlled substance except as prescribed by a member of the medical profession?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)In the past 10 years, have you had or been advised to have counseling or treatment for alcohol or drug use or been advised by a member of the medical profession to limit your use of alcohol or drugs? This includes both prescription and non-prescription drugs.(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Are you now pregnant?(Required)SelectYesNoExpected Delivery Date(Required) MM slash DD slash YYYY Are you currently receiving or within the last 5 years, have you had a sickness, injury or any other condition for which you received or applied for any disability benefits including worker’s compensation, social security disability insurance or any other form of disability insurance?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Within the past 5 years, have you had a physical exam, check-up of any kind or diagnostic tests performed that were not previously disclosed, except for HIV or AIDS tests?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Within the past 5 years, have you been advised by a member of the medical profession to have surgery or any diagnostic tests that were not performed, except for HIV or AIDS tests?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Do you have an appointment scheduled within the next 6 months to seek medical attention, excluding routine physicals?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required)Other than as previously stated on this application, are you currently or in the past 5 years have you received medical advice, counseling, or treatment for any medical, surgical, psychological, or psychiatric condition from a medical professional or have you been a patient in a hospital, clinic, rehabilitation center or other medical facility?(Required)SelectYesNoPlease explain... (if applicable, please include dates, diagnoses, symptoms, treatments, medications, surgeries, disability duration, workdays missed, job restrictions, physical limitations, and provider details (e.g., physicians, counselors, or clinics).(Required) Family HistoryTo the best of your knowledge, have any immediate family members (father, mother or sibling) died before age 60 from cardiovascular disease or cancer?(Required)SelectYesNoTo the best of your knowledge, have any immediate family members (father, mother or sibling) been diagnosed by a member of the medical profession before age 60 with cardiovascular disease or cancer?(Required)SelectYesNoHave any immediate family members been diagnosed or treated by a member of the medical profession for diabetes, mental illness or a hereditary condition of the brain, muscles, nervous system, eyes or kidneys?(Required)SelectYesNoPlease list your immediate family, their current ages, and if they are no longer living, please list their age at death and condition/cause of death. For siblings, please list gender.(Required)
