- Age
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- Weight
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- Height
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- Allergies
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- Current medications
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- Prior surgeries
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- Have you recently had a respiratory infection, such as a cold, flu, or COVID-19?
If COVID-19, when was the date of your diagnosis? |
- Do you have chest pain?
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- Do you have a heart condition?
If yes: Please explain. |
- Do you have hypertension (high blood pressure)?
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- Do you experience shortness of breath?
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- Do you have asthma, bronchitis, chronic obstructive pulmonary disease (COPD) or any other breathing problem?
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- Do you have obstructive sleep apnea (OSA)?
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- Do you currently smoke, or have you ever smoked, cigarettes?
If yes: Packs per day, number of years smoked, date you quit smoking. |
- Do you consume alcohol?
If yes, how many drinks per week? |
- Do you now use, or have you used, recreational drugs?
If so, what type of drug? |
- Have you taken cortisone (steroids) in the last 6 months?
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- Do you take aspirin or any nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, or naproxen?
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- Do you take any herbal supplements, complementary or alternative medicines, or vitamins?
If yes, which ones and how recently? |
- Do you have diabetes? Do you take any medications to treat your diabetes?
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- Have you had hepatitis, liver disease, or jaundice?
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- Do you have a thyroid condition?
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- Do you have, or have you ever had, kidney disease?
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- Do you have ulcers, gastroesophageal reflux (GERD or heartburn), or other stomach disorders?
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- Do you have back or neck pain?
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- Do you have any muscle or nerve disease?
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- Do you or any of your family have sickle cell disease or trait?
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- Have you or any blood relatives had difficulties with anesthesia other than nausea and vomiting?
If yes: Please explain. |
- Do you have a bleeding disorder?
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- Do you have any loose, chipped, or false teeth? Bridgework? Oral piercings?
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- Have you ever received a blood transfusion?
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- Females: Are you pregnant?
If yes, due date: |
