Medical History

Cancer

Heart attack, stroke, or heart disease

COPD, emphysema, or other lung disease

Kidney or liver disease

Diabetes

HIV/AIDS

Alzheimer’s, dementia, or other neurological conditions

None of the above

Height

Weight

Are you currently taking prescription medications?

Yes

No

Do you currently use Tobacco/Nicotine

yes

No

Quit (within the last 12 months)

Have you been hospitalized in the last 2 years for any medical conditions

Yes

No

What Date/Time works best for you?