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** All the information you supply us through this questionaire is processed through our secure server and will not be shared or disclosed in any way except if Dr.Mora considers it necessary to share it only with other doctors.**
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Medical Information
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Personal Information
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What kind of procedure are you interested on?
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Medical Information
Please fill out this medical questionnaire to the best of your knowledge. It will help us make better decision regarding your surgical procedure.
(Yes)   (No) (Yes)    (No)
*Do you have any heart problems?        *Do you have alcohol problems?       
*Do you suffer from asthma?        *Do you have high blood pressure?     
*Do you have coagulation disorders?      *Do you have an ulcer?     
*Do you have diabetes?      *Do you smoke?     
*List any medications you take regularly: Please list your known allergies: List the major, if any, surgeries you have had: 
*Did you have abnormal bleeding after any of them? (Yes) (No)
Is there any other medical issue that we have not asked you about?