Patient Medical Information
Are you being treated for any medical conditions at the present time or have been treated within the least year? Yes No Not Sure
If so, why?
When was your last medical check-up?
Have there been any changes in your general health in the last year? Yes No Not Sure
If yes, please explain
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? Yes No Not Sure
If yes, please list
Do you have any allergies? If you answered yes, please list using the categories below Yes No Not Sure
Medications
Latex/Rubber Products
Other (e.g. Hayfever. Foods)
Have you ever had an uncommon or adverse reaction to any medicines or injections? Yes No Not Sure
If yes, explain
Do you have or have you ever had asthma? Yes No Not Sure
Do you have or have you ever had any heart or blood pressure problems? Yes No Not Sure
Do you have or have ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis) a heart condition from birth (i.e. congenital heart disease) or a heart transplant? Yes No Not Sure
Have you ever had hepatitis, jaundice or liver disease? Yes No Not Sure
Which type of hepatitis?
Do you have a prosthetic or an artificial joint? Yes No Not Sure
If yes, please explain
Do you have a bleeding problem or a bleeding disorder? Yes No Not Sure
If yes please explain
Have you ever been hospitalized for any liness or operations? Yes No Not Sure
If yes, please explain
Do you have any conditions or therapies that could affect your immune system. e.g. leukemia, AIDS, HIV infection, radiotherapy chemotherapy? Yes No Not Sure
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