First Name:
Lastname:
Gender:Por favor, seleccione una opciónmalefemale
Age:
Birthday:
Weight:(lb)
Height:
ft
in
Address:
City:
Phone:
E-mail:
Emergency Contact (Name & Phone):
High Blood Pressureyesno Hypothyroidismyesno Hyperthyroidismyesno Bronchial asthmayesno
Diabetesyesno Canceryesno Obesityyesno Rheumatoid arthritisyesno
Diabetesyesno Hypertension (High Blood Pressure)yesno Rheumatoid arthritisyesno Bronchial asthmayesno
Thyroidyesno [group tiroides_especifica]Specify [/group]
Other Disease?yesno [group enfermedad_especifica]Specify [/group]
Sleep apneayesno [group apnea_cual]Do you use a CPAP machine? [/group]
Medicine allergiesyesno [group cual_alergia]Which? [/group]
Reaction to anesthesia?yesno [group reaccion_anestesia]Specify[/group]
Contraceptive methodyesno [group metodo_anticonceptivo]Specify [/group]
Hospitalizationsyesno [group hospitalizacion_group]Why? [/group]
Surgeriesyesno [group cirugias_group]¿Which and When? [/group]
Blood transfusionsyesno [group transfusiones_group]¿When? [/group]
Do you smoke?yesno [group fuma_group]How many a day? [/group]
Alcoholyesno [group frecuencia_group]How often do you drink? [/group]
¿Drugs?yesno [group droga_group]¿Which drug? [/group]
Any other comments or information you wish to mention?
