CONSTITUTIONAL
EARS-NOSE-MOUTH-THROAT
RESPIRATORY
CARDIOVASCULAR
GENITOURINARY
GYNECOLOGY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
ENDOCRINE
HEMATOLOGIC / LYMPHATIC
GI PAST MEDICAL HISTORY
If Yes, (*Please bring your machine with you for your procedure)
List all medications you are taking (prescription and non-prescription) Please list all pain medication, sleeping pills or nerve pills you are taking even if you only take them occasionally.
Do you have a family history of the following
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