|
Yes |
No |
Question |
| [ ] |
[ ] |
Have
you recently had a cold or the flu? |
| [ ] |
[ ] |
Are
you allergic to latex (rubber) products? |
| [ ] |
[ ] |
Have
you experienced chest pain? |
| [ ] |
[ ] |
Do
you have a heart condition? |
| [ ] |
[ ] |
Do
you have hypertension (high blood pressure)? |
| [ ] |
[ ] |
Do
you experience shortness of breath? |
| [ ] |
[ ] |
Do
you have asthma, bronchitis, or any other breathing problem? |
| [ ] |
[ ] |
Do
you (or did you) smoke?
Packs/day _____.
Number of years _____.
Date you quit ________. |
| [ ] |
[ ] |
Do
you consume alcohol?
Drinks/week _________. |
| [ ] |
[ ] |
Do
you take or have you taken recreational drugs? |
| [ ] |
[ ] |
Have
you taken cortisone (steroids) in the last six months? |
| [ ] |
[ ] |
Do
you have diabetes? |
| [ ] |
[ ] |
Have
you had hepatitis, liver disease, or jaundice? |
| [ ] |
[ ] |
Do
you have a thyroid condition? |
| [ ] |
[ ] |
Do
you have or have you had kidney disease? |
| [ ] |
[ ] |
Do
you have ulcers or other stomach disorders? |
| [ ] |
[ ] |
Do
you have a hiatal hernia? |
| [ ] |
[ ] |
Do
you have back or neck pain? |
| [ ] |
[ ] |
Do
you have numbness, weakness, or paralysis of your extremities? |
| [ ] |
[ ] |
Do
you have any muscle or nerve disease? |
| [ ] |
[ ] |
Do
you or any of your family have sickle cell trait? |
| [ ] |
[ ] |
Have
you or any blood relatives had difficulties with anesthesia? |
| [ ] |
[ ] |
Do
you have bleeding problems? |
| [ ] |
[ ] |
Do
you have loose, chipped or false teeth, or bridgework? |
| [ ] |
[ ] |
Do
you have any oral piercings, (such as studs or rings) in your tongue or lip? |
| [ ] |
[ ] |
Do
you wear contact lenses? |
| [ ] |
[ ] |
Have
you ever received a blood transfusion? |
| [ ] |
[ ] |
(Women)
Are you pregnant?
Due date _____________. |
