SECURED AND CONFIDENTIAL MEDICAL QUESTIONNAIRE

    Date of Birth:
    Who should we thank for referring you to our office ?


    YesNo

    2. Attending physician:



    YesNo


    YesNo


    YesNo

    Are you suffering or have you ever suffered from?


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    HighLow


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    36. Do you have any of the following allergies?


    YesNo


    YesNo


    YesNo



    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


















    I, the undersigned, hereby declare that I have read, understood and answered the above medical questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health.