Medical History

Please fill out the form below

First Name

Last Name

Email Address

Phone Number

Your Current Physical Health:
GoodFairPoor

Do You Have A Personal Physician?
NoYes

Currently Under The Care Of A Physician?
NoYes

Do You Use Tobacco In Any Form?
NoYes

Had Any Metal Rods, Pins Or Implants Placed?
NoYes

Are You Taking Any Medications?
NoYes

Have You Ever Had Any Surgical Procedures?
NoYes

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 ProblemsTuberculosisUlcersOther

Are you allergic to any of the following?
AspirinCodeineDental AnestheticsErythromycinJewelryLatexMetalsPenicillinTetracycline

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

YesNo

Are you pregnant?
NoYes

Are you nursing?
YesNo