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Clinical Information Form
Patient's Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Email
*
Telephone
*
Reason for Referral
*
Occupation
*
Are you right or left handed?
*
Select Option
Right
Left
Do you have any of the following?
Heart Problems
Epilipsy
Seizures
High Blood Pressure
Dizzy Spells
Kidney Problems
Do you smoke?
*
Select Option
Yes
No
If YES, how much?
Are you an ex-smoker?
*
Select Option
Yes
No
Do you drink alcohol?
*
Select Option
Yes
No
If YES, how much?
Are you taking any of the following?
Asprin
Warfarin
Clopidogrel
Plavix
Iscover
Zarelto
Family member history of similar illness?
*
Select Option
Yes
No
Previous illnesses (and year)
Previous operations (and year)
Medications (include dose and frequency)
Allergies?
*
Select Option
Yes
No
Drug (and reaction)
