Medical History

    Do you have diabetes or blood sugar problems?YesNo
    Do you have heart problems?YesNo
    Do you have lung problems such asthma or other other breathing difficulties?YesNo
    Do you have blood pressure problems? YesNo
    Do you have any blood disorders, such as bleeding or clotting problems? YesNo
    Do you have Hep B or Hep C or are you HIV+? YesNo
    Do you have any implants or metal objects in your body? YesNo
    Have you previously had surgery of any type?YesNo
    Do you have any allergies?YesNo
    Do you have any food allergies?YesNo
    Do you have drug allergies?YesNo
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