Health Info

Gender *

Date of Birth *

What is your weight (in pounds)?   *

What is your height (in feet)?   *

Do you have a history of asthma?

Do you have a history of diabetes?

Do you have a history of high blood pressure?

Do you have kids?

Are you still breastfeeding?

Do you smoke hookah?

Are you a smoker?

If you are a smoker, how many times a day do you smoke?

Do you drink alcohol?

Have you tested positive for HIV?

Do you have a history of Hep B or C?

Do you suffer from any other illnesses or conditions?

Do you have any known allergies?

Have you had any surgeries?

Do you take any medication other than vitamins?

When would you like to have your procedures done?

How did you hear about us?