1. Have you had any surgeries in the past?* |
Yes |
No |
Unsure
|
If yes, please list them here: |
|
2. Have you ever had trouble with anesthesia or surgery?* |
Yes |
No |
Unsure
|
3. Has any family member ever had trouble with anesthesia or surgery?* |
Yes |
No |
Unsure
|
4. Have you ever had high blood pressure?* |
Yes |
No |
Unsure
|
5. Do you need or take blood pressure medications?* |
Yes |
No |
Unsure
|
6. Do you ever have chest pain or heaviness or have you ever had a heart attack?* |
Yes |
No |
Unsure
|
7. Do you wheeze, have asthma, have any trouble breathing, snore excessively or have sleep apnea?* |
Yes |
No |
Unsure
|
8. Do you have a cough?* |
Yes |
No |
Unsure
|
9. Do you smoke?* |
Yes |
No |
Unsure
|
If yes, how many packs per day? |
|
10. Do you drink alcohol?* |
Yes |
No |
Unsure
|
11. Do you use any recreation drugs?* |
Yes |
No |
Unsure
|
12. Can you walk up 2 flights of stairs or walk 1 block without chest pain or shortness of breath?* |
Yes |
No |
Unsure
|
13. Have you ever had a stroke or seizure?* |
Yes |
No |
Unsure
|
14. Do you have thyroid problems?* |
Yes |
No |
Unsure
|
15. Do you have kidney/renal problems?* |
Yes |
No |
Unsure
|
16. Do you have arthritis?* |
Yes |
No |
Unsure
|
17. Do you have a bleeding disorder - bleed or bruise easily?* |
Yes |
No |
Unsure
|
18. Do you take blood thinners or a daily aspirin?* |
Yes |
No |
Unsure
|
If yes, please list them here: |
|
19. Do you have Sickle Cell Anemia or trait?* |
Yes |
No |
Unsure
|
20. Do you have Diabetes? * |
Yes |
No |
Unsure
|
If yes, is it: Type I (insulin dependent)? |
Type I |
or Type II (diet or oral medications)? |
Type II |
21. Do you have gastric reflux (heartburn) or a history of hiatal hernia?* |
Yes |
No |
Unsure
|
22. Do you have hepatitis or immune problems?* |
Yes |
No |
Unsure
|
23. Do you have problems with your neck or jaw?* |
Yes |
No |
Unsure
|
24. Do you take regular medications or herbal remedies?* |
Yes |
No |
Unsure
|
If yes, please list them here: |
|
25. To the best of your knowledge, are you allergic to any medications?* |
Yes |
No |
Unsure
|
If yes, please list them here: |
|
26. Are you allergic to latex products?* |
Yes |
No |
Unsure
|
27. Could you be, or is it possible for you to be, pregnant?* |
Yes |
No |
Unsure
|
28. Do you have any dental problems?* |
Yes |
No |
Unsure
|
29. Please indicate if you have any of the following:
Loose Teeth |
Capped Teeth |
False Teeth |