Eligibility Form

YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED.

Fill the forms and then click SUBMIT. If you do not get confirmation your forms were not sent.
Procedure: Patient facilitator name:
*Name: Sex *Age: Date of
Birth:
         
*E-mail: *Height: *Weight: *BMI:
Address: City State Zip 
*Telephone:

 Cell Phone:
Maximum
Weight:		 When? Date of
surgery:
*List all Medicine Allergies:
*Name of
person to contact
(in case of emergency): 		*Emergency
Phone #:
*Any Medical/physical problems (i.e., sleep apnea,
high blood pressure,
diabetes, high cholesterol, blood diseases, neurological disorders, etc)?		 Yes No Do Not Know
  If Yes, please list:
 
Are
you currently taking any medications or herbal supplements?		 Yes No Do Not Know
  If Yes,
please list the name, dosage and reason for this medicine):
 
Is
there any history in your family of diabetes, cancer and/or hypertension?		 Yes No Do Not Know
  If Yes,
please indicate which ones:
 
Any  surgeries (i.e., gallbladder,
appendix, hernia, heart, etc.)?		 Yes No Do Not Know
  If Yes, please list:
 
Do
you have any adverse reaction to anesthesia? 		Yes No Do Not Know
  If Yes, please indicate the
reaction:
 
Do
you have dentures, dental implants, or caps? 		Yes No Do Not Know
  If Yes, please indicate where:
 
Do
you have any children?		 Yes No  
  If Yes, how many?

Do
you have heavy periods? 		Yes No Do not have periods
Do
you smoke? 		Yes No  
  If Yes, how many cigarettes a day?
Do
you drink? 		 Yes No  
  If Yes, how many?

Do
you do drugs? 		Yes No  
  If Yes, what kind & how often?
 
       
For the Following
Questions, Please Indicate “Yes” “No” or “Do Not Know”.  Please
answer all of the questions.
1.   Do you currently take any
of the following medications?		      
a)  Aspirin

(excedrin, anacin,
bufferin)		 Yes No Do Not Know
 
b)  Anticoagulants

(blood-thinning
medicine)		 Yes No Do Not Know
 
c)  Propanol, Verapamil

(heart
rhythm medicines)		 Yes No Do Not Know
 
d)  Diuretics

(water pills)		 Yes No Do Not Know
 
e) Antihypertensive drugs

(blood
pressure pills)		 Yes No Do Not Know
 
f)  Digitalis

(heart pills)		 Yes No Do Not Know
 
g) Stereoids

(prednisone,
cortisone)		 Yes No Do Not Know
2.    Have
you ever been treated for cancer with chemotherapy or radiation therapy? 		Yes No Do Not Know
    If
yes: when:
   
3.   Do you currently have any
problems with your:		      
a)  Liver

(e.g. cirrhosis,
hepatitis, yellow jaundice)		 Yes No Do Not Know
 
b)  Kidneys

(infection, stones,
failure)		 Yes No Do Not Know
 
c) Spleen Yes No Do Not Know
 
d) Blood

(anemia, leukemia)		 Yes No Do Not Know
4.   Have you or anyone in your
family ever had a serious bleeding problem?		 Yes No Do Not Know
5.   Have you ever had
prolonged or unusual bleeding from tooth extractions, cut, surgery or
nosebleed?		 Yes No Do Not Know
6.   Do your gums bleed when
you brush your teeth?		 Yes No Do Not Know
7.   Are you pregnant? Yes No Do Not Know
8.   Is there any possibility
that you are pregnant?		 Yes No Do Not Know
9.   Have been told you have
diabetes?		 Yes No Do Not Know
10.   Do you wake up to urinate
more than once at night?		 Yes No Do Not Know
11.   Do you have muscle cramps
or pains?  		Yes No Do Not Know
12.   Do you have problems with
your lungs or chest? (e.g., chest pain,

skipped heart beats, high blood pressure, smoke one or more packs a day,

shortness of breath, emphysema, asthma, bronchitis)  		Yes No Do Not Know
  if yes please list:
 
13.   Do you have a cough, or
cough frequently?		 Yes No Do Not Know
14.   Do you have epilepsy or
suffer from fits or seizures?		 Yes No Do Not Know
15.  Do you have neck or back
problems?		 Yes No Do Not Know
16.   Are you scheduled to have
an operation?		 Yes No Do Not Know
       If Yes, what operation?