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