Medical/health Status Questionnaire Page 2
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4Medical History - Detail
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Are you currently being treated for high blood pressure?
If you know your average blood pressure, please enter:
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Please check all conditions or diagnoses that apply:
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Abnormal EKG?
Limited Range of Motion?
Stroke?
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Abnormal Chest X-Ray?
Arthritis?
Do You Suffer from
Epilepsy or Seizures?
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Rheumatic Fever?
Bursitis?
Chronic Headaches or
Migraines?
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Low Blood Pressure?
Swollen or Painful Joints?
Persistent Fatigue?
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Asthma?
Foot Problems?
Stomach Problems?
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Bronchitis?
Knee Problems?
Hernia?
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Emphysema?
Back Problems?
Anemia?
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Other Lung Problems?
Shoulder Problems?
Are You Pregnant?
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Recently Broken Bones?
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Has a doctor imposed any activity restrictions? If so, please describe:
Family History
Have your mother, father, or siblings suffered from (please select all that apply):
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Heart attack or surgery prior to age 55.
High cholesterol
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Stroke prior to age 50.
Diabetes
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Congenital heart disease or left
Obesity
ventricular hypertrophy.
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Hypertension
Asthma
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Leukemia or cancer prior to age 60.
Osteoporosis
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Parent category: Life