Medical History
Please rate your general health:
PoorPoorExcellent
Excellent Has there been any change in your health in the past year?
Please list ALL current MEDICATIONS, non-prescription drugs, or herbal remedies:
Do you have any MEDICATION ALLERGIES?
If you do have MEDICATION ALLERGIES, please indicate if any of the following:
Describe the reaction(s) you had:
Have you ever had an allergic reaction to LATEX?
Have you ever had an allergic reaction to any medication?
Please list any SURGERY you have had in the past (tooth extractions AND other body areas such as tonsils, hernia repair, hip or knee replacements, etc.)
Have you ever been hospitalized or visited an emergency room?
Have you ever been diagnosed with a bleeding/clotting disorder?
Were there any anesthetic problems with any previous surgery?
Do you take anticoagulants or blood thinners (Aspirin, Warfarn, Plavix, etc.)
Have you or anyone in your family ever been diagnosed with Malignant Hyperthermia?
Was there any bleeding problems with any previous surgery?
Please list some of the activities you do to stay active:
How many times a week would you do these activities?
If you were to go for a walk, how many blocks could you walk before tiring?
Do you ever get pain in your chest while walking or doing these activities?
Do you ever get short of breath while walking or doing these activities?
