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MEDICAL "'JW'nON"RE PURSUANT To HEALTH a SAFETY CODE 11=3 <br /> T'hi q€s irrrtair r id <br /> -maintain the Privacy a A " d ,off <br /> T y ii <br /> J or a d'0. <br /> I- e you or o#der? <br /> 2.Are you diabetic? <br /> If Yes,you May need to consult yojjr <br /> 3. Have your eaten in#10 loss <br /> .Are you e hili carv gin e . , <br /> rr �rft your . . Yes, you to <br /> e you under the Wluenoe of A oralcohol? <br /> -Are You taldngg any Prescription d <br /> rugs?-L,if <br /> )lease list <br /> 7. Da you have A wn 311e1freeal n to latex, any arstibiolics or taaoo inks? <br /> What Idnd of reaction did you ve'� �If , <br /> ® e y�a�z ever F r ' er iV ir�fe ori <br /> w ori" f L ', <br /> . a yap�€ ° ve t® 'oi7� # <br /> o wafL NO EXCEPTIONS! <br /> 1. re you o rt y 'Yoehavet <br /> Do you have any history 61 cardiar-Wye dzeas,? <br /> . Have you ever. iv ®J; <br /> r�or t � ff y ° <br /> are Procedure. Your.p� 'o- <br /> 1 . 0 you have ui e r inti rior to <br /> stnery 13- deo YOU—-have any .other k 6 o ira PA <br /> ore �r�ce�� <br /> T ? - , <br /> PLEASE <br /> $ - <br /> U <br /> FALSIFYING THIS i <br /> Tint <br /> 4 <br /> 7 <br />