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Height
Weight
Gender

 (If yes, please complete the allergy information below)
 MedicationType of Reaction you experience:
1
 MedicationDate of Operation
2
 MedicationDose Frequency
3
SOCIAL HISTORY  Yes  No
Do you smoke?      If yes, how much per day and how many years?
Have you ever smoked?      If yes, start date/quit date?
Do you drink alcohol?      If yes, how much and how often?
Do you chew tobacco/gutkha?      If yes, please specify.
Date of your last Tetanus Shot?
MEDICAL HISTORY   Self    Family Relationship to you
Arthritis     
Asthma     
Blood Disorder     
Cancer     
Diabetes     
Gastrointestinal     
Genitourinary/Prostate     
Heart Problems     
High Blood Pressure     
High Cholesterol     
Women   Self    Family Relationship to you
Pregnant     
Kidney Problems     
Liver Problems/Hepatitis     
Lung Problems     
Neuro: Seizures, Epilepsy     
Psychiatric     
STD     
Skin Disorders     
Thyroid     
Other