Health Screen Form V2

Name(Required)








DD slash MM slash YYYY

Please enter a number from 1 to 9.

Please enter a number from 1 to 12.

Please enter a number from 2023 to 2099.

Background Information

Your Objectives(Required)









Have You Recently Experienced Any Unexplained Weight Loss?(Required)


I Am A Professional Athlete (governed by WADA and/or ASADA)(Required)


Have You Recently Experienced Any Night Sweats/Fevers?(Required)


Have You Ever Been Diagnosed With Depression?(Required)


Have You Had Any Surgical Procedures In Past 4 Weeks? Or Planning To Have In Next 4 Weeks?(Required)


Have You Ever Been Diagnosed With Cancer?(Required)


Do You Have Family History With Cancer?(Required)


Have You Ever Been Diagnosed With Diabetes Or Abnormal Blood Sugar Levels?(Required)


Do You Have A History Of High Blood Pressure?(Required)


Have You Ever Had A Stroke?(Required)


Have You Ever Been Diagnosed With Heart Conditions?(Required)


Do You Ever Suffer From Chest Pains, Palpitations (Irregular Or Fast Heart Beat), Shortness Of Breath?(Required)


Are You Trying To Conceive (Have A Baby)?(Required)