1 |
Do you have any health problems? If yes, please describe. |
Yes
|
No
|
2 |
Have you had any major surgery? If yes, please describe. |
Yes
|
No |
3 |
Have you had any cosmetic surgery? If yes, please describe. |
Yes
|
No
|
4 |
Do you take any medications/nutritional/herbal supplements? If yes, please describe. |
Yes
|
No
|
5 |
Have you ever had any adverse reaction to local or general anaesthesia? |
Yes
|
No
|
6 |
Do you take aspirin/Blood Thinners/NSAIDS? |
Yes
|
No
|
7 |
Have You had any allergic reactions to any medicines? If yes, please describe. |
Yes
|
No
|
8 |
Do you have any other allergies? If yes, please describe. |
Yes |
No |
9 |
Do you Smoke? If yes, how much and for how long? |
Yes |
No |
10 |
Do you take Alcohol or other recreational drugs? If yes, which ones and frequency. |
Yes
|
No
|
11 |
Are you Pregnant or Lactating? |
Yes |
No |
12 |
Do you have children? If yes, how many and how old is the youngest? |
Yes |
No |