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Medical Questionnaire

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Personal Information
Name:	Required.
Sex:	Male Female
Current Height:
Current Weight:
Blood Type:
Date of Birth:
Phone Number:
E-Mail:

Family Medical History
Have any of you blood relatives (mother, father, brothers, sisters, grandparents, aunts, uncles) had any of the
following diseases or conditions? Please check all that apply


Allergies	High cholesterol	Mental Illness
Glaucoma	Bowel disorder	Stroke
Anemia	Liver disease	Diabetes
Heart disease	Cancer	Thyroid disorder
Blood disorders	Lung disease	Eczema
Arthritis	Cataracts	Ulcer
High blood pressure	Nervous system	Emphysema
Asthma	Depression	Epilepsy
Other

Medical History Have you had any of the following conditions? Please check all that apply

	Cancer	Pacemaker	Kidney Disease
	Diabetes	Vascular Disease	GI Bleeding
	Tuberculosis	High Blood Pressure	Arthritis
	Malaria	Bleeding Disorder	Prostate Disease
	HIV / AIDS	DVT	Hepatitis
	Clotting problems	Glaucoma	Stroke
	Heart Disease	Thyroid Disease	Heart Murmur
	Epilepsy	Heart Attack	Mental Illness
	Abdominal EKG	Lung Disease	Irregular heart beat
	Asthma	Environmental exposures (ex. radiation, chemicals)	Bone / Skeletal problems

Allergies
Do you have any food, medications or other allergies?
Please specify:

Do you or any family members have a history of adverse reaction to local anesthetic or general anesthesia? Yes No

Do you currently smoke? Yes No

How many cigarettes per day?
For how long?

Past Surgical History Please list any prior surgeries with approximate dates

Surgery		Date

Medication History Please list any medications you are currently taking, including prescriptions and any over the counter medications (pain relievers, vitamins, homeopathic medications, etc…)

Medication	Dosage and frequency

Have you ever received blood transfusions or blood components?

Yes No

If yes, did you have any type of adverse reaction?

Yes No

Check all Immunizations that you have received:

		Date		Date
	Hepatitis A		Tetanus (Td/Tdap)
	Typhoid		Other (Please specify, include dates)

To the best of my knowledge, all the questions on this Medical History form have been accurately answered. I understand that providing incorrect information can be dangerous to my health, and that is my responsibility to inform the physician of any changes in medical status.

Payment

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Address 2:	(optional)
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ZIP Code:	(5 or 9 digits)
Country:	United States
Amount:	USD