Merital Status Single Married Divorced Widowed Name Surname E-Mail Birthday Weight Height BMI Index Occupation Country Phone Number Address/City/State Smoking (if yes, quantity) Alcohol (if yes, quantity) Other Substances (if yes, specify) Date of last menstrual period Prescriptions/Medications Number of pregnancies Number of live births Last childbirth (date) Method of Birth Control (Specify) If Menopausal, date of onset Drug Use Yes No Drug Allergies/Adverse Reaction Yes No Reaction to Anaesthesia Yes No Blood Transfusion Yes No Sexually Transmissed Disease Yes No Hepatitis Yes No HIV Yes No Breast Feeding Yes No Hereditary Health Concerns Yes No Diabet Yes No Insulin Yes No Oral Antidiabetic Pills Yes No Blood Pressure Yes No Cholesterol Yes No Cancer Yes No Kidney Disease Yes No Epilepsy or Seizures Yes No Anemia Yes No Asthma/Emphysema Yes No Gallbladder Disease Yes No Difficulty in Swallowing/Stroke Yes No Joint Pain Yes No Constipation or Diarrhea Yes No Swollen Glands Yes No Anxiety Yes No Pelvic Pain Yes No Reflux Yes No Shortness of Breath Yes No Difficulty Sleeping/Apnea Yes No Nausea Yes No Dizziness Yes No Burning w/Urination Yes No Hot Flashes Yes No Murmur (Heart Disease) Yes No Cardiac Failure (Heart Disease) Yes No Surgical History (State any surgical procedure) Surgical History Date Message (if have any) I have read and agree the “Customer/Patient Clarification Text” and “Patient Explicit Consent Letter” SEND HEALTH-CHECK FORM Modal title × …
