| Please check all that apply to you:
|
Are you presently taking prescription medications?
(with the exception of birth control or anti-malarial) | |
| Could you be pregnant, or are you attempting to become pregnant? | |
| Have you ever had or do you currently have…
|
| • Asthma, or wheezing with breathing, or wheezing with exercise? | |
| • Frequent or severe attacks of hayfever or allergy? | |
| • Frequent colds, sinusitis or bronchitis? | |
| • Any form of lung disease? | |
| • Pneumothorax (collapsed lung)? | |
| • Other chest disease or chest surgery? | |
• Behavioral health, mental or psychological problems
(panic attack, fear of closed or open spaces, depression)? | |
| • Epilepsy, seizures, convulsions or take medications to prevent them? | |
| • Recurring migraine headaches or take medications to prevent them? | |
| • Blackouts or fainting (full/partial loss of consciousness)? | |
• Frequent or severe suffering from motion sickness
(seasick, carsick, etc.)? | |
| • Dysentery or dehydration requiring medical intervention? | |
