Your Age
Your Weight (Kg)
Your Length(cm)
Do you suffer from any illness or health problem? For example, pressure, sugar or cholesterol ……? YesNo
If yes, please mention it ?
Do you use any kind of medications? Or vitamins? YesNo
Do you suffer from any type of allergies? YesNo
If yes, please mention them?
Do you use aspirin or any of the blood thinners? YesNo
Have any previous surgeries been performed? YesNo
Have you had the following? HIVHepatitis CNothing
Do you smoke? YesNo
If yes, please mention how many cigarettes per day are you smoking?
Do you drink alcoholic beverages? FrequentlyOccasionallyNo
Do you use any kind of drugs (Marijuana, Cocaine…)? YesNo
The information you presented on this form is true and accurate to the best of your knowledge at the time of consult.
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