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Please check any of the following that apply

 Pre Med - Amoxicillin Alcohol Abuse Allergy - Aspirin Allergy - Latex Allergy - Vicodin Allergy - Codeine Allergy - Erythromycin Allergy - Sulfa Allergy - Penicillin Anemia Ankle Swelling Anticoagulant Arthritis Artificial Heart Artificial Joint Blood Disease Blood Transfusion Cancer Diabetes Dizziness / Fainting Epilepsy Glaucoma Heart Attach Heart Disease Heart Murmur High Blood Pressure HIV Jaundince Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems Rheumatic Fever Sinus Problems Stomach Problems Stroke Tumors Ulcers Venereal Disease Allergy - Other Allergies (Hay Fever) Arteriosclerosis Asthma Chemotherapy Excessive Bleeding Head Injuries Hepatits Jaundice Mitral Valve Prolapse Pregnancy Rheumatism Tuberculosis Drug Abuse Pregnant Smoker Blood Thinners

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