1 |
Do you have any health problem.? if yes, please described |
Yes
|
No
|
2 |
Have you had any major surgery.? if yes, please described |
Yes
|
No |
3 |
Have you had any cosmetic surgery.? if yes, please described |
Yes
|
No
|
4 |
Do you take any medication/nutritional supllements/herbal medications.? if yes, please described |
Yes
|
No
|
5 |
Have you ever had any adverse reaction to local or general Anesthesia |
Yes
|
No
|
6 |
Do you take aspirin/Blood Thinnerss |
Yes
|
No
|
7 |
Have You Had any allergic Reaction to medicine.?if yes, What type and what year |
Yes
|
No
|
8 |
Do you have any allergy.? if yes, please described |
Yes |
No |
9 |
Do you Smoke.? if yes, how much |
Yes |
No |
10 |
Do you take Alcohal or other reaction medicines/drugs.? if yes, how much |
Yes
|
No
|
11 |
Are you Pregnant/Lactating |
Yes |
No |
12 |
Do you have any children.?if yes, how many and how old is the youngest |
Yes |
No |