Try-Out Health History Questionnaire

Form Template

Here are some questions posed by this health questionnaire.

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Have you ever suffered a head injury / concussion and/or been knocked unconscious? Have you ever suffered a cervical spine / neck injury? Have you ever suffered a shoulder injury? Have you ever suffered an elbow / forearm injury? Have you ever suffered a wrist, hand, and/or finger injury? Have you ever suffered a spine, low back, and/or sacroiliac injury? Have you ever suffered a rib, thorax, and/or chest injury? Have you ever suffered a hip, groin, and/or thigh injury? Have you ever suffered a knee injury? Have you ever suffered an ankle, lower leg, and/or foot injury? Have you ever suffered a heat-related illness and/or received intravenous fluids (IV) for a heat-related problem?

Features
  • Signature Capture
  • Submission Editing
  • Reference Data
  • Dispatch
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Platforms
  • iPhone
  • iPad
  • Android
  • Windows
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Integrations
  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”

Dave Kramer, PennLine Service

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