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% <br /> Personal Medical History <br /> yo <br /> Name: <br /> Alcoholism Diabetes STDS <br /> Blood Pressure Drug Addiction Sleep apnea <br /> Alzheimer's Depression Schizophrenia <br /> Arthritis Hearing Impairment Skin Cancer <br /> Anxiety Heart Attack Sickle Cell Anemia <br /> Asthma Heart Disease Tuberculosis <br /> Anemia Hemophilia or Other bleeding disorders Thyroid Problems <br /> Anaphylaxis Hepatitis A,B, C Tetanus <br /> Allergic Reaction to Latex Herpes Infection at the Procedure Site DTI <br /> Allergic Reaction to Antibiotics HIV Ulcer <br /> Amblyopia Kidney DlSeaaeS Vertigo <br /> Breast Cancer liver Oisease Vitamin Deficiency <br /> Bowel Disease Lupus Visual Impairment <br /> Blood Clots Migraine Notes <br /> Pregnant Mental Illness <br /> Bipolar Disorder obesity <br /> Bronchitis OCO <br /> Cardiovascular Disease Osteoporosis <br /> Cardiac Valve Disease Prostate Cancer <br /> Cervical Cancer PTSD <br /> CON Parkinson's <br /> Crohn's Disease Seizures <br /> Cholesterol Stroke <br /> - �_.- - - <br />