Chiari Medical History

All fields with an asterisk (*) are required.

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2022-CONT-Medical Center of Aurora-Chiari Medical History-PHI
Name*
Have you ever had any of these medical illnesses? (Mark all that apply)
Have you been diagnosed or treated for blood clots?*
Have you ever had cancer?*
Have you ever had a problem with anesthesia?*
Have you ever had problems with wounds healing?*
Have you used any illicit drugs?*
Do you use tobacco products? *

Family History

Has your MOTHER had any serious/chronic illnesses?*
Has your FATHER had any serious/chronic illnesses?*
Have your SIBLING(S) had any serious/chronic illnesses?*

Social History

Are you:*
Do you live:*
Employment*

Allergies

Are you allergic to any of the following? (Mark all that apply)

Current Medications