Name Surname Phone Birth Day Occupation Height Weight BMI Index Country Address/City/State Have you had any operations? Have you ever been hospitalized for reasons other than operations? Please list all medicines you take now and specify doses: (include over-the-counter medicines and supplements) Please list any allergies or reactions Blood transfusion Yes No Anemia Yes No Asthma/Emphysema Yes No Arthritis Yes No Bladder or Kidney Infections Yes No Blood Clots / Bleeding disorders Yes No Chronic Diarrhea Yes No Diverticulosis Yes No Diabetes Yes No Epilepsy or Seizures Yes No Gallstones / Gallbladder Disease Yes No Gout Yes No Heart Disease Yes No Cholesterol Yes No High Blood Pressure Yes No Kidney Disease/Stones Yes No Liver Disease/Hepatitis Yes No Lung Disease/Pneumonia Yes No Polyps Yes No Rheumatic Fever Yes No Sleep apnea Yes No Stroke Yes No Thyroid Disease/Goiter Yes No Ulcers (stomach or intestinal) Yes No Reflux Yes No Sexually-transmitted disease Yes No Smoking: Yes No Alcohol: Yes No Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills? Notes Terms and Conditions I agree to Terms Conditions. Send
