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Medical History Form
Name
*
E-mail
*
Phone
*
Gender
*
Female
Male
Date of Birth
*
Weight in kilograms
*
Height in cm
*
Blood Type
Choose your blood type
A Rh(+)
A Rh(-)
B Rh(+)
B Rh(-)
AB Rh(+)
AB Rh(-)
0 Rh(+)
0 Rh(-)
Heart Disease
*
No
Yes
Chest Pain
*
No
Yes
Heart Murmur
*
No
Yes
High Blood Pressure
*
No
Yes
Shortness of Breath
*
No
Yes
Asthma/Emphysema
*
No
Yes
Blood with Coughing
*
No
Yes
Anesthetic Reaction
*
No
Yes
Diabetes
*
No
Yes
Reflux Disease
*
No
Yes
Thyroid Disease
*
No
Yes
Arthritis
*
No
Yes
Kidney Stones
*
No
Yes
Blood in your Urine
*
No
Yes
Stroke
*
No
Yes
Nervous Disorder
*
No
Yes
Blood Transfusion
*
No
Yes
HIV
*
No
Yes
Hepatitis
*
No
Yes
Bleeding Tendency
*
No
Yes
Stomach Ulcers
*
No
Yes
Hernia Repairs
*
No
Yes
Cancer
*
No
Yes
Do you have cancer in your family history?
*
No
Yes
Previous Surgeries, if you had any
*
No
Yes
If yes, please specify previous surgeries
Are you allergic to any medications?
*
No
Yes
If yes, please list all allergic medications
Do you smoke?
*
No
Yes
If yes, how much a day? (smoke)
Do you drink alcohol
*
No
Yes
If yes, how much a day? (alcohol)
Terms & Conditions
*
I read and accept terms and conditions
Medical History Form Confirmation
*
I have read, understand and agree to the medical history form and take full responsibility of my answers.
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