Patient Medical Form

Name :

Date of Birth :

Weight in Kilograms:

Height in cm. :

Heart Disease. :YesNo

Chest PainYesNo

Heart MurmurYesNo

High Blood PressureYesNo

Shortness of BreathYesNo

Asthma / EmphysemaYesNo

Blood with CoughingYesNo

Anesthetic ReactionYesNo

DiabetesYesNo

Reflux DiseaseYesNo

Thyroid DiseaseYesNo

ArthritisYesNo

Kidney StonesYesNo

Blood in your urine YesNo

Stroke YesNo

Nervous Disorder YesNo

Blood Transfusion YesNo

HIV YesNo

Hepatitis YesNo

Bleeding Tendency YesNo

Stomach Ulcers YesNo

Hernia Repairs YesNo

Cancer YesNo

Do you have cancer in your family YesNo

Pervious Surgeries, If you had any YesNo

If yes, please specify pervious surgeries:

Please list all the medications you are presently taking :

Are you allergic to any medications? (Please list) :

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? :

Do you smoke? YesNo

If yes, how much a day? (smoke) :

Do you drink alcohol? YesNo

If yes, how much a day? (alcohol) :

Terms & Conditions:

Medical History Form Confirmation:

Your email