Medical Health History


eNRG Performance team member *
Name *
Name
Address *
Address
Date of birth *
Date of birth
Do you have asthma or exercise induced asthma? *
Have you ever had a seizure? *
Do you have epilepsy? *
Have you been diagnosed with any type of diabetes, pre-diabetes, insulin resistance, or do you have a high fasting blood sugar? *
Are you or have you been anemic? *
Have you been diagnosed with disordered eating or an eating disorder? *
Are you being treated for high blood pressure? *
Do you have or have you ever had heart disease? *
To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)? If so, please explain *
Do you have any risk factors for metabolic syndrome (large waist circumference, high triglycerides, high blood pressure, low HDL, high fasting blood sugar)? *
Do you have or have you ever had lung disease? *
Do you have or have you ever had kidney disease? *
Do you have or have you ever had liver disease? *
Do you or have you ever had stomach disease (ulcers, bleeding, etc.) or any bowel condition/disease (IBS, IBD, Crohn’s, etc.)? *
Do you or have you ever had frequent headaches? *
Do you or have you ever had a hernia? *
Have you ever had a concussion or head injury? *
Have you ever had a broken bone or fracture? *
Have you ever had a shoulder injury? *
Have you ever had a hip or knee injury? *
Do you wear any removable dental appliances that affects your chewing or swallowing ability? *
Females only
Are you pregnant?
For all individuals
The above answers have been answered correctly and truthfully to the best of my knowledge *

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