Medical formThis form must be updated every six months. Formulario Médico 1.1 EN (#10)First NameLast nameEmailPhoneDate of birthI authorize the use of my photos in publications Yes NoAnteriorSiguiente1. I have had problems with my lungs/breathing, heart, or blood. Yes NoA) I have/have had asthma, wheezing, severe allergies, hay fever or congested airways in the last 12 months that limit my physical activity/exercise. Yes NoB) I have/have had chest surgery, heart surgery, heart valve surgery, stent placement or a pneumothorax (collapsed lung). Yes NoC) I have/have had a problem or illness that affects my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR I am taking medication for a heart condition. Yes NoD) I have/have had recurrent bronchitis and a current cough in the last 12 months, OR I have been diagnosed with emphysema. Yes NoE) I have a COVID-19 diagnosis. Yes No2. I am over 45 years old. Yes NoA) I am over 45 years old AND I currently smoke or inhale nicotine by other means. Yes NoB) I am over 45 years old AND I have a high cholesterol level. Yes NoC) I am over 45 years old AND I have high blood pressure. Yes NoD) I am over 45 years of age AND I have had a close relative who died suddenly or from heart disease or stroke before the age of 50, OR I have a family history of heart disease before the age of 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). Yes No3. I have difficulty performing moderate exercise (e.g., walking 1.6 kilometers/one mile in 14 minutes or swimming 200 meters/yards without resting), OR I have been unable to participate in normal physical activity due to fitness or health reasons in the past 12 months. Yes No4. I have had problems with my eyes, ears, or nasal passages/sinuses. Yes NoA) I have had sinus surgery in the last 6 months. Yes NoB) I have/have had an ear disease or ear surgery, hearing loss, or balance problems. Yes NoC) Recurrent sinusitis in the last 12 months. Yes NoD) Eye surgery in the last 3 months. Yes No5. I have had surgery in the last 12 months OR I have persistent problems related to previous surgeries. Yes No6. I have lost consciousness, had migraine headaches, seizures, stroke, major head injury, or suffer from a persistent neurological injury or disease. Yes NoA) I have/have had a head injury with loss of consciousness in the last 5 years. Yes NoB) I have/have had a persistent neurological injury or disease. Yes NoC) I have/have had recurrent migraine headaches in the last 12 months, or I take medication to prevent them. Yes NoD) I have had fainting spells or blackouts (total or partial loss of consciousness) in the last 5 years. Yes NoE) I have/have had epilepsy, seizures or attacks, OR I take medication to prevent them. Yes No7. I am currently in treatment (or have required treatment in the last five years) for psychological problems, personality disorder, panic attacks, or drug or alcohol addiction; or I have been diagnosed with a learning disability. Yes NoA) I have/have had behavioral, mental or psychological health problems that require medical/psychiatric treatment. Yes NoB) I have/have had behavioral, mental or psychological health problems that require medical/psychiatric treatment. Sí NoC) I have been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. Yes NoD) I have/have had a drug or alcohol addiction that requires treatment in the last 5 years Yes No8. I have had back problems, hernias, ulcers, or diabetes. Yes NoA) I have/have had recurring back problems in the last 6 months that limit my daily activity. Yes NoB) I have had/have had back or spine surgery in the last 12 months. Yes NoC) I have/have had diabetes controlled with medication or diet, OR gestational diabetes in the last 12 months. Yes NoD) I have/have had an uncorrected hernia that limits my physical abilities. Yes NoE) I have/have had active or untreated ulcers, problematic wounds, or ulcer surgery in the last 6 months Yes No9. I have had stomach or bowel problems, including recent diarrhea. Yes NoA) I have had an ostomy and I do not have medical authorization to swim or do physical activity. Yes NoB) I have had dehydration that required medical intervention in the last 7 days. Yes NoC) I have had active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months. Yes NoD) I have had frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD). Yes NoE) I have had active or uncontrolled ulcerative colitis or Crohn’s disease. Yes NoF) I have undergone bariatric surgery in the last 12 months. Yes No10. I am taking prescription medications (with the exception of birth control pills or antimalarial drugs other than mefloquine/Lariam). Yes NoWrite your name as your signature here I accept the terms described in the participant agreement and in the center’s terms and conditions/a>. ⚠️ You answered YES to questions 3, 5, 10 or any of the letter questions. You must send your answers and ask your doctor to review and complete the medical evaluation form. Previous Send responses
