Patient medical history Have you ever had:Heart Disease* Yes No High Blood Pressure* Yes No Rheumatic Fever* Yes No Diabetes/ inherited Disease* Yes No Allergies* Yes No Asthma, Chest Disease* Yes No Joint Replacement* Yes No Blood Disease/Bleeder etc* Yes No Stomach Ulcers* Yes No Snoring problems* Yes No Infectious Diseases e.g. HIV, AIDS, Hepatitis A, B or C or any other illnesses of significance we should know of?* Are you on any medications e.g. Cortisone, Warfarin?* Females: Are you pregnant? Additional notes and commentsName* First Patient mobile number*Email* Date of Birth* DD dash MM dash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code NameThis field is for validation purposes and should be left unchanged.
