1. Are you currently suffering from any contagious, communicable, or dangerous diseases?

No, I am not.

2. Have you ever been treated for any mental health condition?

No, I have not.

3. Do you have any physical impairments that require regular medical care?

No, I do not have any physical impairments that require regular medical care.

4. Have you had any recent surgery, hospitalization, or serious illness?

No, I have not.

5. Have you ever been treated for a sexually transmitted infection?

No, I have never been treated for a sexually transmitted infection.

6. Are you currently taking any prescribed medications?

Yes, I am taking a medication for high blood pressure.

7. Are you allergic to any medications or foods?

No, I am not allergic to any medications or foods.

8. Do you have a history of drug abuse or addiction?

No, I do not have a history of drug abuse or addiction.

9. Have you ever tested positive for HIV/AIDS or hepatitis B/C?

No, I have not.

10. Have you ever been diagnosed with tuberculosis (TB) or had a positive TB skin test?

No.

11. Have you ever had any of the following conditions: cancer, heart disease, diabetes, asthma, high blood pressure?

No, I have not had any of these conditions.

12. Have you ever been hospitalized for any medical condition in the past year?

No.

13. Are you able to travel safely without assistance and with minimal risk of harm to yourself or others?

Yes, I am able to travel safely without assistance and with minimal risk of harm to myself or others.

14. Have you ever been diagnosed with a mental disorder such as depression or schizophrenia?

No, I have not.

15. Are there any activities your health prevents you from participating in on a regular basis?

Yes, due to a knee injury, I am unable to participate in regular running activities.

16. Do you have any physical disabilities that limit your ability to perform everyday activities?

No, I do not have any physical disabilities that limit my ability to perform everyday activities.

17. How often do you see a primary care provider to monitor and manage your health conditions?

This depends on the individual’s health conditions and needs. Generally, a primary care provider should be seen at least once a year for a physical exam and routine check-up. However, if an individual has chronic health conditions, they may need to see their provider more often to monitor and manage their health.

18. Are there any chronic illnesses or medical conditions that require regular management or monitoring?

Yes, there are many chronic illnesses and medical conditions that require regular management or monitoring, including diabetes, asthma, seizures, hypertension, depression, heart disease, kidney disease, arthritis, HIV/AIDS, and cancer.

19. Are you currently participating in any special dietary programs or taking dietary supplements?

No, I am not participating in any special dietary programs or taking dietary supplements.

20. Are there any other medical conditions not mentioned above that require medical attention and monitoring?

Yes, there are many other medical conditions that may require medical attention and monitoring. Some examples are heart disease, stroke, diabetes, cancer, arthritis, asthma, kidney disease, high blood pressure, chronic obstructive pulmonary disease (COPD), thyroid disease, depression, dementia, and Alzheimer’s disease.