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Past Medical History
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Comments
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Past Surgical History
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Comments
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Please list all known allergies ( environmental, food and medication))
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Any over the counter medication in the last 24 - 48hrs (If yes please list below)
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Medication taken in the last 24 - 48hrs
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Do Any of the following apply to you;
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Anaphylaxis to any medication
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If yes, please list all known medication allergies that result in anaphylaxis
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Heart Disease
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Active infection/ currently taking Antibiotics.
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Kidney/Renal Disease
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Cardiac Arrhythmia
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Peripheral arterialDisease
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GI Bleeding
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Hemophilia/ Bleeding disorders
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Cellulitis (Skin infection)
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Decompensated Cirrhosis
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Peripheral edema, burns, or injuries
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