Quick Health & Activity Check
Please review the following.
If none apply, simply reply ‘No’. If yes to any, let me know the details.
Heart-Related Issues
Coronary Artery Disease
Heart Attack
Coronary Artery Bypass Surgery
Angioplasty
Stent Placement
Angina (chest pain)
Valvular Heart Disease
Cerebrovascular Disease
Cardiomyopathy
Congestive Heart Failure
Congenital Heart Disease
Heart-Related Issues cont. / Respiratory Issues
Stroke
Transient Ischemic Attack (TIA, Mini Stroke)
Abnormal Heart Rhythm
Placement of Pacemaker/Defibrillator
Cerebral, Aortic, or Thoracic Aneurysm
Abdominal Aortic Aneurysm
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Bronchitis
Emphysema
Sarcoidosis
Pulmonary Hypertension
Respiratory Issues cont. / Neurological and Blood Disorders
Cystic Fibrosis
Parkinson’s Disease
Sickle Cell Anemia
Pernicious Anemia
Thalassemia
Clotting Disorders
Lou Gehrig’s Disease (ALS)
Muscular Dystrophy
Demyelinating Disease (including Multiple Sclerosis)
Huntington’s Disease
Hydrocephalus
Neurological and Blood Disorders cont. / Liver Disease
Cerebral Palsy
Quadriplegia
Paraplegia
Liver Disease
Liver Failure
Cirrhosis
Hepatitis (excluding Hepatitis A from which you have fully recovered)
Cancer / Autoimmune and Tissue Disorders
Leukemia
Melanoma
Tumors (benign or malignant) of the brain
Any internal cancer (except basal cell)
Rheumatoid Arthritis
Debilitating or Disabling Arthritis
Chronic Joint or Disc Disease
Systemic Lupus
Scleroderma
Organ Transplant /Seizure Disorder / Mental Health
Organ Transplant Recipient
Ulcerative Colitis
Crohn’s Disease
Epilepsy
Seizure Disorder (diagnosed within the past 6 months)
Seizure Activity or Hospitalization in the last 12 months
Driving Restrictions due to Epilepsy or Seizure Disorder
Sleep Apnea (diagnosed within the last 6 months)
Not Being Treated (CPAP or BiPAP)
Treatment Does Not Provide Relief of Symptoms
Mild or Situational Depression
Lifestyle & Activity Check
Please answer the following:
-Ever used or convicted of unlawful drug possession?
-Ever convicted of a felony or awaiting trial for one?
-Any driving issues (DUIs, reckless driving, or 3+ moving violations in the last 2 years)?
-Any plans for high-risk activities (skydiving, racing, flying private aircraft, etc.) in the next 2 years?
-If none apply, simply reply ‘No’. If yes to any, let me know the details.