Have you ever been diagnosed with a developmental disability?
Have you had any serious illness, significant operation or hospitialization within the past 5 years?:
Have you had joint replacement surgery (such as: knee, hip, etc) within the past 5 years?:
Are you taking any medication(s) including non-prescription, homeopathic or or natural remedies including diet pills? If so, please list:
Do you have any of the following diseases or problems?
High blood pressure, arteriosclerosis (high cholesterol)
Damaged heart valves, artificial valves or heart murmur
Rheumatic Heart Disease
Heart trouble, angina, stroke, heart attack, or any other heart conditions
Chest pain upon exertion
Shortness of breath after mild exercise
Do your ankles swell
Asthma or hay fever
Diabetes Type I or II
Frequent of recurring mouth sores
Stomach ulcers or hyperacidity
Respitatory problems, emphysema, bronchitis, COPD etc
Arthritis or panful, swollen joints including jaw joint (TMJ)
Persistent cough or cough that produces blood
Epilepsy or neurological disorder
Any disease, drug or transplant operation that has depressed your immune system
Sexually transmitted disease(s)
Fainting spells or seizures
Hepatitis, jaundice or liver disease
Thyroid disease (hypo/hyper)
Low Blood Pressure
Persistent swollen neck glands
Have you had abnormal bleeding?
Have you ever required a blood transfusion?
Do you have any blood disorder such as anemia?
Have you ever had treatment for a tumor or growth?
Do you have a history of sleep apnea? Do you currently use a CPAP machine?
Are you currently taking or have you taken these medication(s) in the past: Bisphosphonate therapy such as Fosamax, Boniva, Zometa, Aclasta, Reclast