Do you take, or have you take in the past Blood-thinners?* YesNo

Penicillin* YesNo

Sulfa Drugs* YesNo

Iodine* YesNo

Tape* YesNo

Latex* YesNo

Aspirin* YesNo

High lipid levels* YesNo

Have you ever had a problem with an anesthetic?* YesNo

Do you smoke cigarettes?* YesNo

Do you drink alcohol?* YesNo

Use recreational drugs?* YesNo

Are you easy fatigued?* YesNo

Do you have shortness of breath?* YesNo

Do you have asthma?* YesNo

Stroke* YesNo

Diabetes* YesNo

Coronary Artery Disease* YesNo

Liver disease* YesNo

Lung disease* YesNo

Renal disease* YesNo

Thyroid disease* YesNo

Hypertension* YesNo

Are you presently, or have you ever taken hormones?* YesNo

Are you presently, or is there a possibility of you being pregnant?* YesNo

Have you had any previous surgery?* YesNo

Do you use or B-PAP while your sleep?* YesNo

Do you exercise?* YesNo