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Medical Inquiry Form

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First Name:	*
Last Name:	*
Home Telephone:	*
Office Telephone:	*
Address Line:	*
Occupation:
Gender	*
Marital Status :	*
Age:	*
Weight:	*
Height
Email Address:	*
Are you currently taking any medications or non prescription drugs or herbs? (Please describe (name and dosage) )
Do you smoke? Frequency?
Do you drink? Frequency?
Do you exercise? Frequency?
Have you taken any cortisone on the past year? If positive Please specify
Are you allergic to any drugs?
Do you suffer any disease like diabetes, high blood pressure, etc? Please specify
Do you have any psychiatric problems?
Have you ever had any surgeries? Describe procedures and dates.
Have you ever had any reaction to any type of anesthesia?
Please tell us which procedure(s) you are inquiring about. Hold the control key down while selecting to highlight multiple procedures.

Please describe any other important details you would like to add*