Medical Screening Recruitment Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email Address
Address
Health Information
Known Medical Conditions
Current Medications
Allergies
Past Surgeries
Lifestyle
Do you smoke?
No
Yes
Former smoker
Do you consume alcohol?
No
Yes
Physical Activity Level
Sedentary
Lightly active
Moderately active
Very active
Emergency Contact
Contact Name
Relationship
Phone Number
Additional Information
Comments/Notes