List ALL allergies to medications:
List ALL (prescription and non-prescription) you currently take:
Check next to any of the symptoms you have had during the past year:
How physically demanding is your job?
Very heavy (frequently lifting > 100 pounds)
Heavy (frequently lifting > 60 pounds)
Moderate (frequently lifting > 30 pounds)
Light (frequently lifting < 30 pounds)
Sedentary (essentially no lifting)
How satisfied are you with job?
It is the worst job I've ever had
What are some of your usual recreational activities that you had participated in the YEAR BEFORE your current problem?Please checkbox in front of those you currently cannot perform.