Medical Form

YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED.

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*All fields with an asterisk are mandatory.

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Do you have any medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurogical disorders, etc)?
Are you currently taking any medications or herbal supplements
Is there any history in your family of diabetes, cancer and/or hypertension?
Have you had any surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)?
Do you have any adverse reactions to anesthesia?
Do you have dentures, dental implants, or caps?
Do you have any children?
Do you have heavy periods?
Do you smoke?
Do you drink?
Do you do drugs?
a) Aspirin (Excedrin, Anacin, Bufferin)
b) Anticoagulants (blood-thinning medicine)
c) Propanol Verapamil
d) Diuretics (water pills)
e) Antihypertensive Drugs (blood pressure pills)
f) Digitalis (heart pills)
g) Steroids (prednisone, cortisone)
2. Have you ever been treated for cancer with chemotherapy or radiation therapy?
a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
b) Kidneys (infection, stones, failure)
c) Spleen
d) Blood (anemia, leukemia)
e) Blood (anemia, leukemia)
4. Have you or anyone in your family ever had a serious bleeding problem?
5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
6. Do your gums bleed when you brush your teeth?
7. Are you pregnant?
8. Is there a possibility that you are pregnant?
9. Have you been told you have diabetes?
10. Do you wake up to urinate more than once at night?
11. Do you have muscle cramps or pains?
12. Do you have problems with your lungs or chest? (e.g. chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day, shortness of breath, emphysema, asthma, bronchitis)
13. Do you have a cough, or cough frequently?
14. Do you have epilepsy, or suffer from fits or seizures?
15. Do you have neck or back problems?
16. Are you scheduled to have an operation?

Medical Advice Disclaimer

The content of the Website, including without limitation, text, copy, audio, video, photographs, illustrations, graphics and other visuals, is for informational purposes only and does not constitute professional medical advice, diagnosis, treatment or recommendations of any kind. Personal results may differ for each individual. You should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because of information provided by this website. Any information provided by International Facilitators Mexico Inc. in person, by telephone or through marketing materials, including but not Wilted to, all print audio and information is for informational purposes only. Reliance on any information appearing on this Website is solely at your own risk.

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