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Were there problems with the general anesthetic
HighLow Blood Pressure
HepatitisJaundice
Kidney Problem
Abnormal Bleeding
HIVAIDS
Birth Control
medical problem
yn2
Asthma
Heart Attack
AnginaChest Pain
Bronchitis
Stroke
Depression
Ulcer
Tuberculosis
Anemia
Alcohol or Drug Use
Seizures
Liver Disease
Arthritis
Rheumatic Fever
MentalNervous Disorder
Cancer
Thyroid Disorder
Diabetes
Immune Deficiency
Radiation Therapy
Glaucoma
Heart Murmur
4 Do you have any other medical conditions not listed you feel we should know about
5 Do you smoke
Women Are you pregnant
Are you breastfeeding
Have you ever had an allergic reaction to medications including latex
Pain Pills
Antibiotics
Heart Pills
Antidepressants
Aspirin
Blood Thinners
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SteroidsCortisone
Inhalers
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03/28/2026Click to Sign
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