EmailMe Form - Long Term Applicant Health Questionnaire

Name

First Last

Are you able to walk 5-6 miles a day? *

Yes

No

Are you underweight or over weight? *

Are you under medical supervision at this time, or presently taking any medication? *

Yes

No

If yes, please list medications and reasons for medical supervision

Do you have any dietary limitations of which we should be aware? *

Are you asthmatic? *

Yes

No

Do you have any allergies? *

Are you able to work outdoors in high temperatures? *

Yes

No

Would you consider yourself to be in generally good health? *

Yes

No

Please make additional comments regarding your health or special limitations affecting physical capabilities.