1. Have you ever had a heart attack?________________ 2. Do you ever have heart trouble?________________ 3. Do you ever have chest pain or Angina?________________ 4. Do you ever have Blood Pressure problems?________________ 5. Do you have a cough?________________ 6. Asthma/Bronchitis/Emphysema?________________ 7. Do you get short of breath climbing one set of stairs?________________ 8. Do you smoke?________________ If yes, how many?________________ 9. Do you drink alcohol?________________ 10. Do you have liver disease?________________ 11. Any history of jaundice?________________ Hepatitis?________________ 12. Any history of thyroid problems?________________ 13. Have you taken Cortisone in the past year?________________ 14. Do you have any kidney problems?________________ 15. Do you have epilepsy?________________ 16. Have you or your family ever had problems with anaesthetics?________________ 17. Do you have any capped/loose/false teeth?________________ 18. Are you pregnant?________________ 19. Do you bruise easily?________________ 20. List ALL Allergies (food/medications/latex) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
21. List ALL current medications ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
22. List any operations you have had ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
