Clinic Platoforms

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What is your middle intial?
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what is your date of birth?
How old are you?
What is your street address?
What city do you live in?
What state do you live in?
What is your zip code?
What is your phone number?
Please enter your social security number
Please enter your driver's license number
In what state was your drivers license issued?
Has your DOT card ever been less than 2 years?
This includes childhood surgeries as well. If you are not sure please mark yes and list below.

Do you have or have you ever had:

Have you ever had a head or brain injury or any head or brain illness?
Have you ever had seizures or been on seizure medication?
Do you have or have you ever had eye problems (except glasses or contacts)
Do you have or have you ever had ear and/or hearing problems?
Do you have or have you ever had heart disease, heart attack, bypass or other heart problems?
Do you have or have you ever had a pacemaker, stents, implantable devices or other heart procedures?
Do you have or have you ever had high blood pressure?
Do you have or have you ever had high cholesterol?
Do you have or have you ever had chronic (long-term) cough, shortness of breath or other breathing problems?
Do you have lung disease or asthma?
Do you have or have you ever had kidney problems, kidney stones or pain/problems with urination?
Do you have or have you ever had stomach, liver or digestive problems?
Do you have or have you ever had diabetes or blood sugar problems?
Do you use or have you ever had to use insulin?
Do you have or have you ever had issues with anxiety, depression, nervousness or other mental health problems?
Do you have or have you ever had issues with fainting or passing out?
Do you have or have you had dizziness, headaches, numbness, tingling, or memory loss?
Do you have or have you ever had unexplained weight loss?
Do you have or have you ever had a stroke, mini-stroke(TIA), paralysis, or weakness?
Do you have or have missing or limited use of arm, hand, finger, leg, foot or toe?
Do you have or have you ever had neck or back problems?
Do you have or have you ever had bone, muscle, joint or nerve problems?
Do you have or have you ever had blood clots or bleeding problems?
Do you have or have you ever had cancer?
do you have or have you ever had chronic(long-term) infection or other chronic disease?
Do you have or have you ever had sleep disorders, pauses in breathing while asleep, daytime sleepiness or loud snoring?
Have you ever been checked or told to get checked for sleep apnea?
Have you ever spent a night in the hospital?
Have you ever had a broken bone?
Have you ever used or do you now use tobacco?
Do you currently drink alcohol?
Have you used an illegal drugs including marijuana within the past two years?
Have you ever failed drug test or been dependent on an illegal substance?
Do you have any health conditions not described in the previous questions?
Did you answer "yes" to questions 1-32?
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