If you have diabetes, please provide your history of diabetes, latest A1C count and a description of your treatment
Please give us a brief description of your blood disorder(s)
Please give us a brief description of your autoimmune disorder(s)
Please tell us the type(s) of cancer, when you were diagnosed, and what your treatment has been.
Please briefly describe any other health issues you have that have not been covered in these questions
How much caffeine do you consume and how often?
How much alcohol do you consume and how often? Example: 1 glass of wine per day
Please describe your tobacco habit. How many cigarettes (or cigars) do you smoke per day? How long have you been smoking?
If you have quit smoking, how long ago did you quit? What did your tobacco habit consist of (how many cigarettes or cigars per day for how long)?
What type of recreational drugs do you use? How often?
If you have struggled, or are currently struggling, with drug and/or alcohol abuse, please describe your history or current circumstances.
If you checked "other food" please list the foods to which you are allergic
If you checked "medications" please list the medications to which you are allergic
Please list all prescription medicine(s) you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
Please list all over-the-counter medicine(s) you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
Please list all supplements you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
Please list your previous surgeries and the dates the procedures were performed.
Please describe your problem with anesthesia
Please tell us who in your family has had a problem with anesthesia, and describe the problem.
