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Patient : Please answer
ALL questions listed by
checking yes or no. |
YES |
NO |
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1. In the last six
months have you had a
heart attack, bypass
surgery, or angioplasty? |
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2. At home, are you
dependent upon OXYGEN ? |
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3. Do you have a
history of any type of
bleeding disorder? |
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4. Do you have an
artificial heart valve or
any history of
Endocarditis? |
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5. Are you on Coumadin,
Aspirin, or any Arthritis
medicine? |
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6. Do you receive
antibiotics before you
have dental work? |
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7. Are you a diabetic
and taking any medication
for it? |
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8. Are you allergic to
Latex? |
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9. Are you allergic to
eggs, soybeans, or
sulfites? |
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10. Are you pregnant or
nursing ? |
* |
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11. Do you take any
vitamins or herbal
supplements? |
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12. Have you ever had
any problems with
Anesthesia? |
* |
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13. Do you have a
history of sleep apnea? |
*
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