Patient Medical History Medical History FormPlease enable JavaScript in your browser to complete this form.Record ID *Name *Phone *Heart Problems ? *YesNoHigh Blood Pressure ? *YesNoRheumatic fever or heart murmur ? *YesNoBlood Diseases ? *YesNoThyroid Problems ? *YesNoJaundice, Hepatitis or Liver Problems ? *YesNoDiabetes or Family history of Diabetes ? *YesNoAsthma, Tuberculosis or Difficulty of Breathing ? *YesNoEpilepsy, had before or family history of Epilepsy ? *YesNoHypertension or Family history of Hypertension? *YesNoMalignant Hyperthermia or Family history of Malignant Hyperthermia ? *YesNoCancer ? *YesNoSeizures ? *YesNoPsychological/Mental Illness ? *YesNoDo you have history of Deep Vein Thrombosis ? *YesNoDo you have Thalassemia or history of Thalassemia ? *YesNoAre you a smoker (cigarette, shisha, other) ? *YesNoAny skin disease ? *YesNoDo you have any Allergies ? *YesNoIf the above answer is YES, Please Specify: *Do you have Drug Allergies ? *YesNoIf the above answer is YES, Please Specify: *Do you ever use Aspirin or Blood Thinners ? *YesNoIf the above answer is YES, Please Specify: *FOR WOMEN ONLYAre you Pregnant or Breastfeeding ?YesNoNumber of Children & Age of youngest Child ?Name all Drugs taken recentlyName all surgeries you had (Please specify with month and date)Terms and Conditions *I agree to the Terms and Conditions.Submit
