1.Do you have any health problems or concerns presently?
2. Has there been ANY change in your general health in the past year?
When did you last have a complete physical exam?
How often do you see your family doctor or specialist?
3. Have you ever been in hospital for treatment?
When, where and why?
4. Have you ever had general anaesthesia or surgery?
5. Have you or any of your family relatives had problems with anaesthesia?
6. Do you have a drug allergy?
7. Do you have any other allergies (e.g. latex)?
8. Do you take ANY prescription medications (including puffers and birth control pills)? If yes provide Pharmacy name + number
9. Do you use or take ANY non-prescription remedies (including herbal remedies)?
10. Have you taken a cortisone (steroid) type drug orally in the past year?
11. Do you or any of your relatives have a bleeding problem?
12. Do you have or have had any difficulty breathing through your nose?
13. Do you have any nose bleeds?
14. Do you have or have had any difficulty breathing while sleeping at home?
15. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?
16. Do you have or have you ever had any of the following?
No to all
Chest pain or angina
Shortness of breath lying down
Irregular heart beat/arrhythmia
High blood pressure
Congenital heart disease
Damaged/abnormal heart valves
HIV, AIDS or STD
Cancer / Chemotherapy
Emphysema / Bronchitis
Cystic fibrosis / Tuberculosis
Fainting spells, dizziness
Adrenal gland problems
Liver disease / Jaundice
Anemia (including sickle cell)
Bleeding (Coagulation) disorders
Stomach ulcers/ Acid Reflux
Bone, joint, or muscle problems
Artificial joints - hips, knees
Depression / anxiety
Vision problems / glaucoma
Autism or Down’s syndrome
Are you pregnant?
Are you a nursing mother?
Any problems with menstruation?
17. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?
18. Do you have any problems opening your mouth wide or moving your neck fully?
19. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?
20. Do you smoke?
21. Do you drink more than 5 alcoholic beverages per week?
22. Do you have a history of alcoholism or drug dependence?
23. Have you taken any “recreational” drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, "crystal meth", codeine, oxycodone or other drugs?
24. Do you have ANY disease, condition or problem not listed above?
25. How much do you weigh?
What`s your height?
Phone cell & home
Pharmacy name & number
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