Please Fill in Our Unnecessarily Invasive Medical Questionnaire
Please indicate if your back door is usually left unlocked
First Name ________________ Last Name ___________________
Preferred Name ____________________
That nickname* that you really hated and that you thought you’d left behind you when you graduated high school __________________
*Note: If you do not have a nickname, please inform our staff and we will provide you with one.
Please indicate your Title:
□ Mr.
□ Master
□ Messrs.
□ Mrs.
□ Mmes.
□ Dr.
□ Dame
□ Da-yam!
□ Your Eminence
□ Dude
□ My Dude
□ Green Bay Packers
□ Miss
□ Mzzzzzz
Where do you live?* (Just for our records. We will not turn up on your doorstep offering you a free medical exam. Okay, we might.)
_______________
_______________
_______________
*Please indicate if your back door is usually left unlocked.
Q1. Where do you spend most of your time in your home?
□ Bedroom
□ Bathroom
□ Top of fridge
□ Hanging from the rafters like a bat
Q2. What is the best way to contact you?
□ In person. On your doorstep.
□ Nigerian spam
□ Gorillagram
□ Elderly woman cosplaying Dick Turpin in your three-season porch
□ Edible bouquet in your toilet
Q3. Please drag and drop the giant eyeball icons over the parts of your body that you find most embarrassing.
Q4. What is your gender?
□ Yes
□ No
□ It cannot be explained. It can only be experienced.
Q5. Have you lost a significant amount of weight over the past three months?
□ No
□ Yes (Please share your secret ______________)
Q6. What is your favorite color of urine?
□ Yellow
□ Orange
□ Blue
□ Atomic purple
Q7, Is your colon “friendly”?
□ No
□ No!
□ More of an acquaintance really. We meet over burritos sometimes.
□ Prefer not to say (but yes)
Q8. Have you ever stuffed a live ferret down your trousers?
□ Yes
□ No (Please explain ______________)
Q9. Have you ever suffered from any of the following conditions? (select all that apply)
□ Irrational fear of Babybel
□ Rational fear of Babybel
□ Rabies
□ Leprosy
□ Rinderpest
□ Decapitation
□ Tank sweat
□ Corrosion
□ Dick Turpin fanservice
□ Tinnitus
Q10. Please indicate which of the following illicit drugs you have consumed in the past year. (check all that apply)
□ Love
□ Final Fantasy
□ Flamin’ Hot Cheetos
Q11. Do you have a family history of any of the following? (check all that apply)
□ Bootlegging
□ Chicken-chasing
□ George
□ Menstrual relay team
Q12. In the past week, have you noticed any of the following emanating from your nose/eyes/ears?
□ Smoke
□ Gravy
□ Crispy Noises
Q13. Please indicate on the diagram the parts of your body that you would not like to have touched by a Scarface hand-puppet. (We will touch you there with the hand-puppet anyway, but we would like to know how uncomfortable it would make you. Say “Hello” to our little friend!)
