Pre-screen Health Questionnaire

Please provide the following details below:

Patient Name *

First

Last

Daytime Telephone Number

Are you pregnant or is there any possibility that you are pregnant?

Have you ever had an anaphylactic reaction to anything?

Have you been under the care of a physician recently?

Have you ever had a complication as a result of general anesthesia?

Do you have any issues with your heart or blood pressure?

Do you have any bleeding disorders or are you on blood thinners?

Do you have asthma or any other breathing disorders?

Are you diabetic?

Have you ever had a brain seizure?

Do you have any kidney or liver problems?

Have you had any steroid treatment in the past year?

Do you have you any history of cancer, chemotherapeutic agents or radiation treatment?

Have you ever taken any immunosuppressants?

Have you taken any medication for osteoporosis?

Is there anything else about your health that we should know about?

Please explain

List all medications your are current taking, including herbal medications.