Weight Loss Surgery? Yes No* When? Other major Surgeries? What and When? Gall Bladder Removal? Yes No When?
1. Med allergic to Type of Reaction: Severity of Reaction: Mild Moderate Severe At what age it occurred? 2. Med allergic to . Type of Reaction: . Severity of Reaction: Mild Moderate Severe At what age it occurred? 3. Med allergic to Type of Reaction: . Severity of Reaction: Mild Moderate Severe At what age it occurred? Type a label
I am pregnant/ I have reason to believe i could be pregnant / I plan to get pregnant during the treatment. # Births Dates: Tubal Ligation Hysterectomy Partial Complete Birth Control None
Coffee Cups/Day: Tea Cups/Day: Cola (any) None
Wine Beer Liquor None No of drinks per week: No of drinks per month:
None Socially No of packs per day: Type a label No of years of smoking: Type a label