Past Medical History |
Are you allergic to any medications? If so, please list them and describe your reaction:
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If you do not have any allergies, please check "No Allergies."
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Are you allergic to any of the following?
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Do you have any problems with anesthesia?
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Do you have a history of motion sickness?
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Do you have a recent history or taking steroid medication?
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Have you ever had a blood transfusion?
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Do you have a history of blood clots?
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Do you or any family member in your household suffer from frequent infections?
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Primary Language:
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Secondary Language (if applicable):
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Please list any and all prescription, non-prescription, and over the counter medications, home remedies, vitamins, birth control pills, inhalers, etc. that you currently take.
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Please list all past surgical procedures, major or minor, that you have had:
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Please list all major illnesses, accidents of injury, or hospitalizations you have had:
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Surgery/Hospitalizations/Deliveries/Plastic Surgery Consultations
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