Bleeding Disorder Yes (Relation/Type):  No Cancer: Yes No (Relation/Type):   Diabetes Yes No (Relation/Type):   Developmental Disorder Yes No (Relation/Type):   Heart Disease Yes No (Relation/Type):   High Blood Pressure Yes No (Relation/Type):   Thyroid Problems Yes No (Relation/Type):   Other: Yes No (Relation/Type):   MEDICATIONS Are you currently on ANY medication:  Yes  No (This includes prescription, over the counter, & vitamins)- please list ALL current Medications NAME OF MEDICATION(S) Dose How Often & When              OVER THE COUNTER MEDICATIONS, HERBAL REMEDIES & VITAMINS DOSE How Often & When      PLEASE BRING CURRENT MEDICATION LIST WITH YOU TO EVERY VISIT! Signature of Patient or Guarantor: ________________________________________________ Date: _______/_____/______
Bleeding Disorder  Yes No (Relation/Type): Cancer:  Yes  No (Relation/Type): Diabetes  Yes  No (Relation/Type): Developmental Disorder  Yes  No (Relation/Type): Heart Disease  Yes  No (Relation/Type): High Blood Pressure  Yes  No (Relation/Type): Thyroid Problems  Yes  No (Relation/Type): Other:  Yes  No (Relation/Type): MEDICATIONS Are you currently on ANY medication:  Yes  No (This includes prescription, over the counter, & vitamins)- please list ALL current Medications NAME OF MEDICATION(S) Dose How Often & When              OVER THE COUNTER MEDICATIONS, HERBAL REMEDIES & VITAMINS DOSE How Often & When      PLEASE BRING CURRENT MEDICATION LIST WITH YOU TO EVERY VISIT! Signature of Patient or Guarantor: ________________________________________________ Date: _______/_____/______
patient-registration-updated-2016-1_-new.docx