Short Form

Please indicate whether any of the following apply to you. If so, please place a check in the blank beside the appropriate item. Thank you.

___________ Hypertension or high blood pressure

___________ A personal OR family history of heart problems or heart disease

___________ Diabetes

___________ Orthopedic problems

___________ Cigarette smoking or other regular use of tobacco products

___________ Asthma or other chronic respiratory problems

___________ Recent illness, fever or Gastrointestinal Disturbances (diarrhea, nausea, vomiting)

___________ Any other medical or health problems not listed above. (Provide details below.)

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List any prescription medications, vitamin/nutritional supplements or over-the-counter medicines you routinely take or have taken in the last five days (including dietary/nutritional supplements, herbal remedies, cold or allergy medications, antibiotics, migraine/headache medicines, aspirin, ibuprofen, birth control pills, etc.)

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I certify that my responses to the foregoing questionnaire are true, accurate, and complete.

Signature:________________________________________________________ Date:_______________