Health Inventory "*" indicates required fields Name* First Last Date of Birth* Month Day Year Email* HiddenToday's Date MM slash DD slash YYYY Have you ever in the past had, or do you currently have, any of the following items? Please check the box of any that apply to you, and please provide the date of when you had the condition in the box below.Chicken pox or shingles* Yes No Night sweats* Yes No Tuberculosis* Yes No Positive TB skin test (PPD)* Yes No Liver disease or hepatitis* Yes No Unintended weight loss* Yes No Immune Suppression* Yes No Chronic or reoccurring infection* Yes No Other contagious diseases* Yes No Do you currently have or have had in the last two weeks any of the following:Diarrhea* Yes No Nausea or vomiting* Yes No Runny nose or sneezing* Yes No Cough* Yes No Fever* Yes No Any additional comments:CAPTCHA
