New Patient Form

Check all that apply

Are you required to be pre-medicated

Blood Problems (Anemia)

Blood Transfusion

Heart Problems

Heart murmur, mitral valve prolapse, or heart defect

Heart Pacemaker

Stroke

Bone or Joint Problems

Artificial Joint or Valves

High Blood pressure

Low Blood pressure

Tuberculosis or Lung problems

Kidney Disease

Hepatitis, jaundice, or other liver disease

Diabetes type 1 or type 2

Epilepsy or Neurological Disorder

Thyroid Problems

Arthritis

Herpes or Cold sores

AIDS or HIV positive

Cancer/Tumor

Abnormal bleeding after any surgery

Hayfever or Sinus Trouble

Allergies

Asthma

Are you allergic to, or have you reacted adversey to any of the following?

Are you taking any of the following?

For Women

Pregnant or planning to become pregnant

Taking hormones or contraceptives

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