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Medical History

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Please Check If You Have Any of the Following Medical Problems*
High Blood Pressure
Asthma / Emphysema
Previous Heart Attack
History of Chest Pain
Diabetes
History of Heart Disease
Tuberculosis
Previous Cancer
Ulcers
Family History of Bleeding Problems
NONE OF THE ABOVE
Are You Allergic to Any Medications?
NO
YES
How Many Drinks of Alcohol Do you Have?
Do You Now Smoke?
NO
YES
Did You Used to Smoke?
NO
YES
Do You Take ANY Medications
NO
YES
I HEREBY CONSENT TO ANY EXAMINATION, LABORATORY TESTS, ANESTHESIA, MEDICAL OR SURGICAL TREATMENT, OR CLINICAL SERVICES DEEMED MEDICALLY NECESSARY BY MY PHYSICIAN*
Patient Signature*