Name
Gender
MaleFemale
Date of Birth
Weight in kilograms
Height in cm
Your Email
Phone Number
Which surgery are you interested in ?
Heart Disease
YesNo
Chest Pain
Heart Murmur
High Blood Pressure
Shortness of Breath
Asthma / Emphysema
Blood with Coughing
Anesthetic Reaction
Diabetes
Reflux Disease
Thyroid Disease
Arthritis
Kidney Stones
Blood in Your Urine
Stroke
Nervous Disorder
Blood Transfusion
HIV
Hepatitis
Bleeding Tendency
Stomach Ulcers
Hernia Repairs
Cancer
Do you have cancer in your family history?
Previous Surgeries
If yes, please specify previous surgeries
Please list all 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?
If yes, how much per day?
Do you drink alcohol?
I have read and accept the Terms & Conditions.
I have read, understand and agree to the Medical History Form and take full responsibility for the accuracy of my answers.
