Pre-COVID-19 Chest History Please enable JavaScript in your browser to complete this form.DateHave You Had Any of the Following?PalpitationsFainting SpellsRaised Blood PressureHeart ProblemsDizzinessCollapsesPneumoniaPleurisyAsthmaHave You or a Family Member Ever Had:Heart AttackHypertensionHigh CholesterolDiabetesStrokeDo You Smoke or Have You Ever Smoked?YesNoWould You Consider Your Lifestyle to be:Extremely ActiveActiveModerately ActiveSedentaryHeight in InchesWeight in PoundsIs Your Blood Pressure:NormalLowElevatedSignificantly ElevatedDon't knowIs Your Cholesterol Level:NormalLowElevatedSignificantly ElevatedDon't knowSubmit