American Triumph - Healthcare Questionnaire

Personal Information

First Name *

Middle Name *

Last Name *

Date of Birth * +

Gender *

Position *

Stated Height in Inches *

Weight in Pounds *

Contact Information

Street Address *

City *

State/Province/Region *

County *

Zip/Postal Code *

Country *

Phone Number *

Email Address *

Health History - To Be Completed by Patient

IF PREGNANT, PLEASE ADVISE PHYSICIAN

Have you at any time in the past or present experienced or been diagnosed with the following conditions:

ABDOMEN & CHEST *

	YES	NO
Chronic Coughing	YES	NO
Asthma	YES	NO
Tuberculosis or Chest Disease	YES	NO
Household contact with anyone with TB	YES	NO
Blood in sputum or when coughing	YES	NO
Pneumonia	YES	NO
Other Lung or Respiratory Problems	YES	NO
Hernia or Rupture	YES	NO

CARDIAC PART A *

	YES	NO
Shortness of breath	YES	NO
Chest Pain or Angina	YES	NO
Heart Disease	YES	NO
Pacemaker	YES	NO
Myocardial Infarction	YES	NO

CARDIAC PART B *

	YES	NO
Palpitating / Irregular Heartbeat	YES	NO
Leg cramping	YES	NO
High Blood Pressure	YES	NO
Dizziness or Fainting Spells	YES	NO

HEAD *

	YES	NO
Wear corrective lenses	YES	NO
Eye surgery to correct vision	YES	NO
Lack vision in either eye	YES	NO
Wear a hearing aid	YES	NO
Eye Trouble or Disease	YES	NO
Ear, Nose or Throat Trouble	YES	NO
Recurrent ear infections	YES	NO
Chronic or frequent colds	YES	NO
Tooth/gum issues or broken teeth	YES	NO
Chronic sinus conditions	YES	NO
Head injury or concussion	YES	NO
Frequent or severe headaches	YES	NO

ENDOCRINE *

	YES	NO
Easily fatigued	YES	NO
Diabetes	YES	NO
Recent gain or loss of weight	YES	NO
Thyroid Disorders	YES	NO

GASTROINTESTINAL *

	YES	NO
Hepatitis or Jaundice	YES	NO
Gallbladder trouble or gallstones	YES	NO
Stomach or Intestinal Problems	YES	NO
Liver, Kidney Problems	YES	NO
Hemorrhoids or rectal disease	YES	NO
Ulcers	YES	NO
GERD	YES	NO
H. Pylori infection	YES	NO

MENTAL HEALTH *

	YES	NO
Sleep Disorders	YES	NO
Depression or anxiety	YES	NO
Suicide attempt or plans	YES	NO
Use illegal substances	YES	NO
Psychotic Episodes	YES	NO

NEUROLOGICAL *

	YES	NO
Loss of memory or amnesia	YES	NO
Periods of unconsciousness	YES	NO
Epilepsy, Convulsions	YES	NO
Any Neurological Disorders	YES	NO
Nerve injury	YES	NO

ONCOLOGY *

	YES	NO
Radiation therapy	YES	NO
Chemotherapy	YES	NO
Cancer	YES	NO
Anemia or Blood Disorders	YES	NO

URINARY *

	YES	NO
Frequent or painful urination	YES	NO
Kidney stone or blood in urine	YES	NO
Sugar or protein in urine	YES	NO
Sexually transmitted diseases	YES	NO

ORTHO *

	YES	NO
Plate, pin or rod in any bone	YES	NO
Swollen or painful joints	YES	NO
Broken bones or fractures	YES	NO
Arthritis, Muscle, or Bone Problems	YES	NO
Loss of finger or toe	YES	NO
Painful shoulder or elbow	YES	NO
Recurrent back pain or any back injury	YES	NO
Knee pain or locked knee	YES	NO
Foot trouble	YES	NO

OTHER *

	YES	NO
Adverse reaction to medication	YES	NO
Recent hospitalizations	YES	NO
Car, train, sea or air sickness	YES	NO
Skin diseases	YES	NO
Allergy, Hay Fever	YES	NO
Abnormal bleeding or bruising	YES	NO
Other medical problems not listed	YES	NO
Asbestos or toxic chemical exposure	YES	NO

If you answered YES to any of the items above, provide details including a description, dates, and treatments.

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Please list any allergies including insect bites/stings and common foods (please list) or else enter N/A: *

	Allergy	Reaction
Allergy + Reaction 1	Allergy	Reaction
Allergy + Reaction 2	Allergy	Reaction
Allergy + Reaction 3	Allergy	Reaction

Please list any non-prescription and/or prescription medication you are currently taking. Please include the reason and dosage or else enter N/A:

Medication *

	Details
Medication 1	Details
Medication 2	Details
Medication 3	Details

Reason & Dosage

	Reason & Dosage Details
Reason & Dosage 1	Reason & Dosage Details
Reason & Dosage 2	Reason & Dosage Details
Reason & Dosage 3	Reason & Dosage Details

Certification

PLEASE READ CAREFULLY AND SIGN.

I, THE UNDERSIGNED, HEREBY CERTIFY THAT ALL THE INFORMATION IS TRUE.

I AUTHORIZE ANY DOCTOR, HOSPITAL, CLINIC AND ANY OTHER HEALTH FACILITY TO DISCLOSE TO MY EMPLOYER, AND ITS DESIGNATED ADMINISTRATORS IF APPLICABLE, ALL WRITTEN INFORMATION TAKEN DURING THE EXAMINATION OR STATED ON THIS FORM FOR THE PURPOSES OF DETERMINING FIT FOR DUTY STATUS OR THE ABILITY TO SAFELY PERFORM MY JOB DUTIES. I AM WILLING TO SUBMIT TO ANY REQUIRED TESTS NECESSARY TO COMPLETE THIS EXAMINATION.

Signature *

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Date * +