YES OR NO HELP ME

1. Are you in good health?
2. Are you under medical treatment now?
If yes, what is the condition being treated?___________
3. Have you ever had a serious illness or surgical
operation?
If Yes, what illness or operation? ___________
4. Have you ever been hospitalized?
If yes, When, and why you were hospitalized?_________
Are you taking prescription or non-prescription
medication?
If yes, please specify._______
6. Do you use tobacco products?
7. Do you use alcohol, cocaine, or other dangerous drugs?
8. Are you allergic to any of the following?
( ) local anesthetic (ex. Lidocaine)
( ) Penicillin, Antibiotics
() Sulfa drugs
( ) Aspirin
( ) Latex
( ) Others​_________​