You will be required to fill this form out when you get to Dr. Valero’s office for your first consultation. Most people coming to the office are women, but we also have forms for gentleman.

You can print this questionnaire in PDF format, fill it out, and bring it with you to your appointment, otherwise, you will be handed one in the office for you to fill in. Please call in advance to the office (619) 730-1917 or  Local 684-2551 for us to set an appointment.

Do you have allergies?

Have you had any surgery?

Do you take medicines daily?

Do you have high blood pressure?

Do you Smoke?

Do you drink alcohol?

Do you exercise?

2 + 11 =

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