Background Medical History

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    Name: E-mail:
    Date:

    Do you have any of the following medical problems?

    CONDITION

    High Blood Pressure: YesNo
    Diabetes on Insulin: YesNo
    Diabetes on oral meds only: YesNo
    Hypothyroidism: YesNo
    Heart disease: YesNo
    Osteoporosis: YesNo
    Gout: YesNo
    Parkinson’s: YesNo
    Epilepsy: YesNo
    Depression: YesNo
    Breast Cancer: YesNo
    Prostate Cancer: YesNo
    Other Cancer: YesNo
    Disease Affecting Immune System: YesNo
    Rheumatological Disorder: YesNo

    Do you have any of the following?

    CONDITION

    On a blood thinning agent: YesNo
    Have you had heart surgery: YesNo
    Have you had lung surgery: YesNo
    Have you had peripheral joint surgery: YesNo
    Have you had spine surgery: YesNo
    Have you had abdominal surgery: YesNo
    Do you smoke currently: YesNo
    Have you ever been a smoker: YesNo
    Do you have an allergy to medication that you are aware of: YesNo
    Have you or a family member had Deep Vein Thrombosis: YesNo

    Details: of Meds and/or other yes answers: