Health Form DTS Health Form - Jun 2021 "*" indicates required fields First Name* First Last Name* Last Email* Gender* Female Male Date of Birth* Month Day Year Height*Weight (please specify lbs or kg)*Personal History: Please answer all questions. Please answer all questions. Have you ever had the following conditions or procedures? Explain any “Yes” answers in the space provided. Epilepsy* Yes No Please Explain:Fainting Spells* Yes No Please Explain:Mental Nervous Disorder* Yes No Please Explain:Asthma* Yes No Please Explain:Eating Disorder* Yes No Please Explain:Intestinal or Stomach Troubles* Yes No Please Explain:Recurrent Diarrhea* Yes No Please Explain:Anemia* Yes No Please Explain:Central Nervous Disorder (i.e. Multiple Sclerosis)* Yes No Please Explain:AllergiesFood* Yes No Please Explain:Medications* Yes No Please Explain:Please list and explain any other health issues, medical conditions, or physical disabilitiesAre you currently under a doctor's care for any condition?* Yes No Please Explain:*Are you taking medication at this time?* Yes No Please Explain:*Do you have a history of emotional instability or psychiatric treatment?* Yes No Please Explain:*Can you walk 3-4 miles per day?* Yes No Health InsuranceHealth Insurance Company NameInsurance Policy NumberEmergency ContactName* First Last Relationship*Phone*Additional Phone NumberSignaturePlease type your full name to certify your agreement that the information provided is accurate and truthful*Today's Date* MM slash DD slash YYYY Δ
