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Date: 11/20/2019Please list any medications or drugs you are allergic to:Please list any medications or drugs you are currently taking:Pace MakerHeart MurmurHeart TroubleCancerDrug AddictionDiabetesBlood DiseaseMitral Valve ProlapseRadiation TherapyHerpesTuberculosisProsthetic JointAIDS/ HIVEpilepsyLow Blood PressureSpontanious BleedingHepatitis A, B, CHigh Blood PressurePsychological DisorderAsthmaLatex AllergyOrgan TransplantAlcoholismDysenteryDo you ever have hives or skin rashes?UlcerCheck any medical conditions you may have:Do you bleed a long time when you are cut?Do you have a pacemaker?Do you have any chest pain on exertion?Do you often feel exhausted or fatigued?Have you ever been seriously ill?Have you been a patient in the hospital in the last 3 years?Have there been any changes in your health this year?Are you pregnant?Please check the box if answer is yes.Medical Doctor:First Name:DOB:Medical History UpdateLast Name: