Health Questionnaire

Identification File

Personal History

Have you been diagnosed with hepatitis?

Are you allergic to latex?

Allergic to any medicine or food?

Have you had any surgery for weight control?

Have you suffered a heart attack?

Digestive

Have you been diagnosed with diverticulitis?

Do you have a history of ulcers?

Have you been diagnosed with ulcerative colitis?

Do you suffer from indigestion or reflux?

Have you had any Anti-Reflux surgery?

Diabetic History

Additional Information