Questionnaire Page 3 | stirredwater

Questionnaire - Part II - Health History (continued)

Please select NOW if you're currently dealing with the condition, or PREVIOUSLY if you've experienced it in the past.
If neither apply, choose NEVER.

Childhood Diseases and Illness

Allergies .....

Asthma .....

Atopic Eczema (Rubella) .....

Bronchitis .....

Chicken Pox .....

German Measles .....

Mumps .....

Rheumatic Fever .....

Tonsillitis .....

Whooping Cough ......
Other ......

Angina .....

Arrhythmias .....

Arteriosclerosis .....

Bruises Easily .....

Capillary Fragility .....

Cardiac Arrest .....

Chest pains .....

Congenital Deformaties .....

Congestive Heart Failure .....

Edema .....

Fast Heart Beat .....

High Blood Pressure .....

Heart Attack .....

Heart Flutter .....

Heart Irregularities .....

Heart Murmur .....

Low Blood Pressure .....

Mitral Valve Prolapsed .....

Palpitation .....

Poor Circulation .....

Rheumatic Fever .....

Slow Heart Beat .....

Stroke .....

Varicose Veins .....

Other .....

Ear Infections .....

Earaches .....

Hearing Loss .....
Overly Sensitive Hearing .....

Tinnitus / Ringing .....

Wax Build-up .....

Other .....

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Cardiovascular Health

Ears and Hearing

Return to Page 2

Continue to Page 4

Questionnaire - Part II - Health History (continued)

Childhood Diseases and Illness

Allergies .....

Asthma .....

Atopic Eczema (Rubella) .....

Bronchitis .....

Chicken Pox .....

German Measles .....

Mumps .....

Rheumatic Fever .....

Tonsillitis .....

Whooping Cough ...... Other ......

Angina .....

Arrhythmias .....

Arteriosclerosis .....

Bruises Easily .....

Capillary Fragility .....

Cardiac Arrest .....

Chest pains .....

Congenital Deformaties .....

Congestive Heart Failure .....

Edema .....

Fast Heart Beat .....

High Blood Pressure .....

Heart Attack .....

Heart Flutter .....

Heart Irregularities .....

Heart Murmur .....

Low Blood Pressure .....

Mitral Valve Prolapsed .....

Palpitation .....

Poor Circulation .....

Rheumatic Fever .....

Slow Heart Beat .....

Stroke .....

Varicose Veins .....

Other .....

​

Ear Infections .....

Earaches .....

Hearing Loss ..... Overly Sensitive Hearing .....

Tinnitus / Ringing .....

Wax Build-up .....

Other .....

​

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Cardiovascular Health

Ears and Hearing

Whooping Cough ......
Other ......

Hearing Loss .....
Overly Sensitive Hearing .....