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