AIDS Glaucoma Pulmonary disease / Anemia Heart attack Renal dialysis Alzheimers Heart disease Renal disease / Cesarean section Kidney stone / Amputation Gallbladder surgery Pacemaker Heart bypass Thyroid surgery Hemorrhoid / Breast surgery Hernia / Mitral valve prolapse Diabetes M / Cataract / /
MedicalTreatment
Thyroid surgery / Ear surgery / Gallbladder surgery / Amputation / Breast surgery / Heart bypass / Back surgery / Colon surgery / Lung surgery / Joint replacement / Hysterectomy / surgery / Renal dialysis / Vasectomy / Orthopedic surgery / Cataract surgery / Blood transfusion / /
MEDICAL HISTeR-¥-_ This information is to enable us to help maintain the highest standards of safe and effective treatment. If the patient is a minor, the parent or legal guardian must complete this questionnaire and si