|
|
yes |
no |
|
yes |
no |
|
1.Could you be pregnant or are you attempting to become pregnant? |
|
|
18.History of back surgery? |
|
|
|
2.Do you regularly take prescription or nonprescription medications?(with the exception of birth control) |
|
|
19.History of diabetes? |
|
|
|
3.Are you over 45 years of age and currently smoke a pipe, cigars, or cigarettes? |
|
|
20.History of back, arm or leg problems following surgery, injury or fracture? |
|
|
|
4.Are you over 45 years of age and have a high cholesterol level? |
|
|
21.
Inability to perform moderate exercise (example: walk one mile within 12 minutes)? |
|
|
|
5.Are you over 45 years of age and have a family history of heart attacks or strokes? |
|
|
22.History of high blood pressure or take medicine to control blood pressure? |
|
|
|
6.Asthma, or wheezing with breathing, or wheezing with exercise? |
|
|
23.History of any heart disease? |
|
|
|
7.Any form of lung disease? |
|
|
24.
History of heart attacks? |
|
|
|
8.Pneumothorax (collapsed lung)? |
|
|
25. Angina or heart surgery or blood vessel surgery? |
|
|
|
9.History of chest surgery? |
|
|
9.History of chest surgery? |
|
|
|
1026.שחפת |
|
|
26.History of ear or sinus surgery? |
|
|
|
10.Claustrophobia or agoraphobia (fear of closed or open spaces)? |
|
|
27.History of ear disease, hearing loss or problems with balance? |
|
|
|
11.Behavioral health problems? |
|
|
28.History of problems equalizing (popping) ears with airplane or mountain travel? |
|
|
|
12.Epilepsy, seizures, convulsions or take medications to prevent them? |
|
|
29.History of bleeding or other blood disorders? |
|
|
|
13. Recurring migraine headaches or take medications to prevent them? |
|
|
30.History of any type of hernia? |
|
|
|
14.History of blackouts or fainting (full/partial loss of consciousness)? |
|
|
31.History of ulcers or ulcer surgery? |
|
|
|
15. Do you frequently suffer from motion sickness (seasick, carsick, etc.)? |
|
|
32.History of colostomy? |
|
|
|
16.History of diving accidents or decompression sickness? |
|
|
33.History of drug or alcohol abuse? |
|
|
|
17.History of recurrent back problems? |
|
|
