1) What is your height and weight? (note: this is based on what your physicians records would have)
2) Any smoking past 3 years? (Cigarettes; Cigars; Pipes)
3) Any pulmonary issues? [Asthma, COPD, Emphysema, etc ]
4) Any orthopedic issues? (Back, Neck, Knee, Hips, etc ) (Any cortisone or other injections past 6 months? or pain medications needed? or P.T. or O.T. needed?)
5) Any diagnoses of Arthritis? [Osteo or Rheumatoid]
6) Any history or Osteoporosis?
7) Any history or Diabetes?
8 ) Any heart disease? (Stents; Angioplasty; A-Fib; Heart Attack; Valve Replacement; etc )
9) Any history of high blood pressure?
10) Any history of Strokes; TIAs; Parkinsons; MS?
11) In your last lab work, was everything in the normal range? (Are your red and white blood cells and platelets in the normal range?)
12) Are your liver and kidney functions in the normal range?
13) Any history of cancer?
14) Any nodules on Lungs or other organs that are being followed by a physician?
15) Any history of depression or anxiety?
16) Any circulatory issues? [such as DVT]
17) Any history of mixed connective tissue disease or fibromyalgia
18) What medications are you taking?
19) Any hospitalizations the past 5 years?
20) Do you use a handicapped parking sticker?
21) Have you been on any disability? (social security, group or individual disability or workers comp)
22) Any future or pending surgery required or requested by the physician that is in the medical records?
23) Any memory loss or mention to the physician about memory that would be in the medical records?
24) Any CT Scans or MRIs of the brain or other areas in the past 5 years? If so, was anything found ?
25) Any health issues that need further evaluation or tests?
Prepared by: Michael D. Berk CPA, CLU, ChFC, CLTC (516)208-7731 cell: (516)241-4813