Participant Questionnaire

Formulario Médico 1.1

First Name

Last Name

Phone/Mobile

Date of Birth

I authorize the use of my photos in publications

Yes

1. I have had problems with my lungs/breathing, heart or blood.

Yes

A) I have/have had asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise

Yes

B) I have/have had chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).

Yes

C) I have/have had a problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.

Yes

D) I have/have had recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema

Yes

E) I have a diagnosis of COVID-19.

Yes

2. I am over 45 years of age.

Yes

A) I am over 45 years of age AND I currently smoke or inhale nicotine by other means.

Yes

B) I am over 45 years of age AND I have a high cholesterol level

Yes

C) I am over 45 years of age AND I have high blood pressure.

Yes

D) I am over 45 years of age AND I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Yes

3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months

Yes

4. I have had problems with my eyes, ears, or nasal passages/sinuses.

Yes

A) I have/have had sinus surgery within the last 6 months.

Yes

B) I have/have had Ear disease or ear surgery, hearing loss, or problems with balance.

Yes

C) Recurrent sinusitis within the past 12 months.

Yes

D) Eye surgery within the past 3 months.

Yes

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

Yes

A) I have/have had head injury with loss of consciousness within the past 5 years

Yes

B) I have/have had persistent neurologic injury or disease.

Yes

C) I have/have had recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes

D) I have/have had blackouts or fainting (full/partial loss of consciousness) within the last 5 years

Yes

E) I have/have had epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.

Yes

A) I have/have had behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes

B) I have/have had major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes

C) I have/have had been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.

Yes

D) I have/have had an addiction to drugs or alcohol requiring treatment within the last 5 years

Yes

8. I have had back problems, hernia, ulcers, or diabetes

Yes

A) I have/have had recurrent back problems in the last 6 months that limit my everyday activity.

Yes

B) I have/have had back or spinal surgery within the last 12 months.

Yes

C) I have/have had diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.

Yes

D) I have/have had an uncorrected hernia that limits my physical abilities.

Yes

E) I have/have had active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months

Yes

9. I have had stomach or intestine problems, including recent diarrhea.

Yes

A) I have had ostomy surgery and do not have medical clearance to swim or engage in physical activity

Yes

B) I have had dehydration requiring medical intervention within the last 7 days.

Yes

C) I have had active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.

Yes

D) I have had frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).

Yes

E) I have had active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes

F) I have had bariatric surgery within the last 12 months.

Yes

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

Yes

Type your name as sign here

I accept the terms described in the participant agreement and in the store terms and conditions.

⚠️ You answered YES to question 3, 5, 10, or any of the lettered questions. You must submit your responses and have your doctor review and complete the medical evaluation form. A copy of the medical form will be sent to your email for completion.