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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