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PERSONAL INFORMATION

Birthday
Month
Day
Year

MEDICAL INFORMATION

Are you currently under the care of a physician?
Yes
No
Are you in good health?
Yes
No
Has there been any change in your general health within the past year?
Yes
No
Have you had a serious illness, operation, or been hospitalized in the past 5 years?
Yes
No
Do you take any blood thinners?
Yes
No
Do you take aspirin on a regular basis?
Yes
No
Are you taking or have you recently taken any prescription or over the counter medication(s)?
Yes
No

WOMEN ONLY

Date of last menstrual period
Month
Day
Year
Are you pregnant?
Yes
No
Taking birth control or hormonal replacements?
Yes
No
Nursing?
Yes
No

ALL PATIENTS PLEASE COMPLETE

Do you use controlled substances (drugs)?
Yes
No
Do you use tobacco?
Yes
No
Quit
Do you drink alcoholic beverages?
Yes
No

ALLERGIES

Are you allergic or have you had a reaction to:
Do you have or have you ever had any of the following diseases or problems?
Do you have any disease, condition, or problem not listed above?
Yes
No

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