Quick Health & Activity Check Part 2
Please review the following.
If none apply, simply reply ‘No’. If yes to any, let me know the details.
Organ Transplant /Seizure Disorder / Mental Health
Organ Transplant Recipient
Ulcerative Colitis
Crohn’s Disease
Epilepsy
Seizure Disorder or Activity
Mental incapacity
Schizophrenia
Suicide attempt
Bipolar Disorder
Sleep Apnea (diagnosed within the last 6 months)
Treatment Does Not Provide Relief of Symptoms
Mild or Situational Depression
Any other nervous disorder
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
Physician Visits & Health Updates
1. Have you seen any kind of medical provider in the past 15 years?
2. In the past year, has a doctor recommended any treatment, surgery, or hospital stay that you haven’t done yet?
3. In the past 2 years, has a doctor referred you to another doctor or specialist for something you haven’t followed up on yet? Or have you seen any other medical provider we haven’t already talked about?
4. n the past 2 years have you had any lab work, tests, or procedures come back abnormal? Or anything that needs more testing or follow-up? Or still waiting on results?
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.