20181024_ABOT_Patient_Registration_JM

medical problem
yn2
Were there problems with the general anesthetic
Asthma
Heart Attack
AnginaChest Pain
Bronchitis
Stroke
HighLow Blood Pressure
Depression
Ulcer
HepatitisJaundice
Tuberculosis
Anemia
Alcohol or Drug Use
Seizures
Kidney Problem
Liver Disease
Arthritis
Rheumatic Fever
MentalNervous Disorder
Cancer
Thyroid Disorder
Abnormal Bleeding
Diabetes
Immune Deficiency
Radiation Therapy
Glaucoma
Heart Murmur
HIVAIDS
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
Blood Pressure Pills
Insulin
Birth Control
SteroidsCortisone
Inhalers
Other
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11/10/2026Click to Sign
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