Please check all that apply to you:
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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…
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• 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? | |