Evaluation Survey Form

Section 1: General Information (Mandatory)
Section 2: Medical Survey (Mandatory)
Have you ever had any of the following conditions?
Have you ever had any of the following pulmonary or lung problems?
Do you currently have any of the following symptoms of pulmonary or lung illness?
Have you ever had any of the following cardiovascular or heart problems?
Have you ever had any of the following cardiovascular or heart symptoms?
Do you currently take medication for any of the following problems?
If you've used a respirator, have you ever had any of the following problems?