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 Dont Know
If Yes, please list:
Are

you currently taking any medications or herbal supplements?		  Yes No Dont 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 Dont Know
If Yes,

please indicate which ones:
Any surgeries (i.e., gallbladder,

appendix, hernia, heart, etc.)?		  Yes No Dont Know
  If Yes, please list:
 
Do

you have any adverse reaction to anesthesia? 		 Yes No Dont Know
If Yes, please indicate the

reaction:
 
Do

you have dentures, dental implants, or caps? 		 Yes No Dont Know
If Yes, please indicate where:
Do

you have any children?		  Yes No
If Yes, how many?
Do

you have heavy periods? 		 Yes No Dont Know
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 Dont Know
b) Anticoagulants

(blood-thinning

medicine)		  Yes No Dont Know
c) Propanol, Verapamil

(heart

rhythm medicines)		  Yes No Dont Know
d) Diuretics

(water pills)		  Yes No Dont Know
e) Antihypertensive drugs

(blood

pressure pills)		  Yes No Dont Know
f) Digitalis

(heart pills)		  Yes No Dont Know
g) Stereoids

(prednisone,

cortisone)		  Yes No Dont Know
2. Have

you ever been treated for cancer with chemotherapy or radiation therapy? 		 Yes No Dont Know
If

yes: when:
3. Do you currently have any

problems with your:
a) Liver

(e.g. cirrhosis,

hepatitis, yellow jaundice)		  Yes No Dont Know
b) Kidneys

(infection, stones,

failure)		  Yes No Dont Know
c) Spleen  Yes No Dont Know
d) Blood

(anemia, leukemia)		  Yes No Dont Know
4. Have you or anyone in your

family ever had a serious bleeding problem?		  Yes No Dont Know
5. Have you ever had

prolonged or unusual bleeding from tooth extractions, cut, surgery or

nosebleed?		  Yes No Dont Know
6. Do your gums bleed when

you brush your teeth?		  Yes No Dont Know
7. Are you pregnant?  Yes No Dont Know
8. Is there any possibility

that you are pregnant?		  Yes No Dont Know
9. Have been told you have

diabetes?		  Yes No Dont Know
10. Do you wake up to urinate

more than once at night?		  Yes No Dont Know
11. Do you have muscle cramps

or pains? 		 Yes No Dont 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 Dont Know
if yes please list:
13. Do you have a cough, or

cough frequently?		  Yes No Dont Know
14. Do you have epilepsy or

suffer from fits or seizures?		  Yes No Dont Know
15. Do you have neck or back

problems?		  Yes No Dont Know
16. Are you scheduled to have

an operation?		  Yes No Dont Know
If Yes, what operation?