Bathtub Slip Resistance Study Participation

Medical History Form

Study Title: Adult Bathing Surface Slip Resistance (II)

Date: Participant Code Number (ID):

^{Sex: Male Female Age: Height (ft/in): Weight (lb):} Other Study Specific Measurement(s): In Case of an Emergency, Contact:

GENERAL INFORMATION
Do you experience: Shortness of breath Dizziness Headache Easily fatigued Pain in arm, shoulder or chest	NO NO NO NO NO	YES YES YES YES YES
Are you able to walk 25 feet?	NO	YES
Do you require an assistive device when walking (i.e. cane, walker)	NO	YES
Have you had surgery in the past 6 weeks? If yes, when?	NO	YES
Do you have a mental, cardiac, respiratory and neuro-degenerative disorder ?	NO	YES