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Mrs
Ms
Miss
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Mr_1
Mrs_1
Ms_1
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Allergies
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Are you currently under the care of a physi
Has there been any change in your general health in the past year?
Have you gained or lost weight recently?
Do you get short of breath?
Have you been hospitalized?
Have you ever had surgery?
Have you ever had an unusual reaction to local anesthesia?
Have you ever had a general anesthetic?
Have you or family member had an unusual reaction to a general anesthetic?
Do you have a family history of deaths during surgery?
Do you have a family history of malignant hyperthermia?
Have you had any joints replaced?
Do you wear contact lenses?
Do you have or have a history of any of the following?
New Field
Are you currently being treated for anything on this list?
Are you pregnant at this time?
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Aclasta
Actonel
Aredia
Atelvia
Binosto
Bondronat
Boniva
Benefos, Loron
Didronel
Fosamax, Fosamax Plus D
Neridronate
Olpadronate
Prolia/Xgeva
Reclast
Skelid
Zometa
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Have you had flu like symptoms in the past 14 days?
Have you close contact with someone who has or suspects to have COVID-19 in the past 14 days?
Have you traveled out of South Dakota in the last 14 days?
Have you been in contact with anyone from outside South Dakota?
03/28/2026Click to Sign
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