NEW - Medical History Questionnaire

Member Information

Please provide the following information for the Member requesting a medical history review.
Are you applying for a new Membership, or are you an existing Solidarity Member?*

I am applying for a new MembershipMy minor dependent is applying for Membership, and I am submitting on their behalf.I am an existing MemberMy minor dependent is an existing Member, and I am submitting on their behalf.
Membership ID Number*
Member Name*

First NameLast Name
Member Date of Birth*

MonthDayYear
Date
Member Phone Number*
Please enter a valid phone number.
HIDDEN - DATE FIELD CALCULATOR - DO NOT REMOVE*

MonthDayYear
Date
HIDDEN AGE OF APPLICANT - DO NOT REMOVE
Member Email Address*
example@example.com
Name of Parent or Legal Guardian Submitting Medical History*

First NameLast Name
Parent or Legal Guardian Email Address*
example@example.com
Parent or Legal Guardian Phone Number*
Please enter a valid phone number.
Is the parent or legal guardian also an active Solidarity Member?*

YesNo

Review Medical History

Please review the medical information provided to confirm accuracy prior to submission
Member Information

Member Name: {memberName}

Date of Birth: {DateofBirth}

Email Address: {EmailAddress}

Phone Number: {PhoneNumber}

Medical History

Age:

{hiddenAge}

Height:

{MemberHeight}

Weight:

{MemberWeight} lbs

QUESTION	ANSWER
Have you used nicotine or tobacco products (cigarettes or vaping) in the past 5 years?	{TabaccoNicotine}
Have you ever been diagnosed with diabetes, high blood pressure, high cholesterol, or osteoporosis?	{DiganosedConditionsSW}
Have you ever had a health condition that needed regular treatment, medicine, or follow-up care?	{RegularTreatmentCondition}
Are you currently taking, or have you been prescribed in the last 24 months, any medication, supplements, and/or medical equipment?	{RXSupplementsMedEquipment}
Within the past 24 months, have you seen a healthcare provider(s) for any reason other than routine wellness or cold/flu symptoms?	{24MonthsHealthCare}
Have you ever had any surgeries or hospitalizations?	{SurgeriesHospitalizations}
Are you currently pregnant?	{Pregnancy}
Do you have any other conditions that you think we should know about?	{OtherConditions}

Acknowledgement

By signing below, I declare that the medical health history that I provided is as complete and accurate to the best of my ability. I also acknowledge that I have read and understand the pre-exisiting conditions policy outllined in the Sharing Guidelines.
Member Signature*

Clear
Today's Date*

MonthDayYear
Date
Parent or Legal Guardian Signature*

Clear
Please verify that you are human*
Should be Empty:

Medical History Questionnaire