Date Name Last name Treatment Type Age Height Weight List of medications you are currently using (including over-the-counter medications) List of surgeries you have performed before (including plastic surgeries) Date of Intervention Surgical Intervention Use herbal supplements or vitamins (especially Gingko, ginger, garlic, St. John’s Wort, C, E, fish oil)? Medicines that cause allergies Are you a smoker? YesNo If yes; For how long? Are you an alcohol user? YesNo If yes; For how long? Do you have any of the following symptoms? Chest pain YesNo Breast diseases YesNo Seizure YesNo Heart problems YesNo Tooth problems YesNo High blood pressure YesNo Hepatitis C YesNo Emotional problems YesNo Diabetes YesNo Kidney problems YesNo HIV YesNo Cancer YesNo Asthma YesNo Eye problems YesNo Problems with bleeding YesNo
