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HEALTH QUESTIONNAIRE
Please answer all questions related to your current health status:
Are you currently under medical treatment? If so, please detail.
Are you taking any medication? If so, please list all?
Have you ever suffered from: (please check all that apply)
High Blood Pressure
Hepatitis
Alcoholism
Epilepsy
Rheumatic Fever
Heart Attack
Gastritis
Diabetes
Respiratory Problems
Use Illegal Drugs
Smoking
Asthma
Anemia
AIDS
Venereal Disease
Other (not mentioned above)
More details:
Have you ever had surgery?
Are you allergic to anesthesia? (Y/N)
Are you allergic to any medication?
Please describe:
Do you suffer from hemophilia? (Y/N)
Are you pregnant or nursing? (Y/N)
If pregnant, how many months?
Ailment for which you were referred to us:
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