Name of General Practitioner

Have you ever had or do you currently have any of the following? (Tick all that apply):

List all medications you are currently taking

Any known allergies (medications, materials, etc.)

Previous surgeries or hospitalizations (please specify)

Any history of unusual bleeding or bruising Yes No

Are you pregnant or breastfeeding? Pregnant Breastfeeding No

Do you smoke? Yes No Former

Do you consume alcohol? Yes No Occasionally

Any specific concerns or relevant medical history?