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?

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?