| |
No |
Yes |
| Do you have any health problems? If Yes, please
describe: |
|
|
| Have you had any major surgery? If Yes, please
describe: |
|
|
| Have you had any cosmetic surgery? If Yes,
please describe: |
|
|
| Have you any major injuries? If Yes, please
describe: |
|
|
| Do you take any medications/nutritional
supplements/herbal medications? If Yes, please describe: |
|
|
| Have you ever had any adverse reaction to local
or general anesthesia? |
|
|
| Do You take Aspirin/Blood Thinners? |
|
|
| Have you had an allergic reaction to
medication? If Yes, what type and what year: |
|
|
| Do you any allergies? If Yes, please describe:
|
|
|
| Do you have any bleeding problems? If Yes,
please describe: |
|
|
| Do you smoke? If Yes, how much? |
|
|
| Do you take alcohol or other recreation
medicines/drugs? If Yes, please describe: |
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|
| Do you have any children? If Yes, how many, and
how old is the youngest? |
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