Patient Registration Form

Asthma	YesNo
Autoimmune Disease	YesNo
Allergies or adverse drug reaction	YesNo
Smoker	YesNo
If yes, how many per day?
Rheumatic Fever / Heart Disease	YesNo
High Blood Pressure	YesNo
Epilepsy / Stroke	YesNo
Mental Health Conditions	YesNo
Heart (Pacemaker / Valve / Surgery)	YesNo
Heart Murmur / Defect	YesNo
Bleeding Excessively	YesNo
Ulcer / stomach concerns	YesNo
Diabetes	YesNo
Thyroid Problems	YesNo
Kidney Problems	YesNo
Liver Problems	YesNo
Arthritis / Osteoporosis	YesNo
Joint Replacement	YesNo
Date of surgery
Transplant	YesNo
Recent Operations (last 12 months)	YesNo
Oncology (Cancer Treatment)	YesNo
HIV / Hepatitis	YesNo
Headaches / Migraines	YesNo
Do you snore?	YesNo
Do you clench or grind?	YesNo
Are you pregnant?	YesNo
Due Date
Are you breastfeeding?	YesNo
Do you wake up feeling refreshed in the morning?	YesNo