First Name

Last Name

Middle Initial

Email

Your Current Physical Health:
GoodFairPoor

Do You Have A Personal Physician?
NoYes

Physician’s name:

Physician’s phone:

Date Of Last Visit:

Currently Under The Care Of A Physician?
NoYes

Please Explain:

Do You Use Tobacco In Any Form?
NoYes

Had Any Metal Rods, Pins Or Implants Placed?
NoYes

Are You Taking Any Medications?
NoYes

Please List Each One:

Have You Ever Had Any Surgical Procedures?
NoYes

Please List Each One:

Do you have any of the following?
Abnormal BleedingAlcohol AbuseAllergiesAnemiaAngina PectorisArthritisArtificial Heart ValveAsthmaBlood TransfusionCancerChemotherapyColitisCongenital HeartDefectDiabetesDifficulty BreathingDrug AbuseEmphysemaEpilepsyFacial SurgeryFainting SpellsFever BlistersFrequent HeadachesGlaucomaHIV+ AIDSHeart AttackHeart MurmurHeart SurgeryHemophiliaHepatitis AHepatitis BHepatitis CHigh Blood PressureJoint ReplacementKidney ProblemsLiver DiseaseLow Blood PressureMitral Valve ProlapsePace MakerPsychiatric ProblemsRadiation TherapyRheumatic FeverSeizuresSexually Transmitted DiseaseShinglesSickle Cell DiseaseSinus ProblemsStrokeThyroid ProblemsTuberculosisUlcers
Other:

Are you allergic to any of the following?
AspirinCodeineDental AnestheticsErythromycinJewelryLatexMetalsPenicillinTetracycline
Other:

If Female, Please Answer:
Are you taking Birth Control Pills?
YesNo

Are you pregnant?
NoYes

If so, # of weeks:

Are you nursing?
YesNo