Epidural Form

All fields are required except Social Security Number.

Patient Information
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Sex
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Previous Anesthesia
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Current Medications
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Do you take blood pressure medication?
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Do you take steroid medication?
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Do you use eye drops?
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Allergies
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Have you or any of your family ever had an unusual reaction to anesthesia?
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Do you have or wear?
Permanent Dental Bridges, Crowns, Caps
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Removable Dentures
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Chipped or Damaged Teeth
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Contact Lenses
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Do you have or have you had?
Severe Headaches
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Glaucoma or Eye Problems
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Ear Problems or Hearing Loss
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Nasal Obstruction
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Recent Cold, Flu or Sore Throat
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Pneumonia
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Bronchitis
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Asthma
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Emphysema
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Tuberculosis
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Shortness of Breath
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Heart Problems
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Chest Pains (Angina)
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Heart Attack
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Heart Murmur
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Rheumatic Fever
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High Blood Pressure
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Stroke
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Circulatory Trouble
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Jaundice or Hepatitis
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Stomach or Intestinal Trouble
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Hiatus Hernia or Severe Heartburn
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Recent Nausea or Vomiting
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Kidney Disease
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Bladder Problems
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Difficulty Urinating
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Sexually Transmitted Disease
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Bleeding Tendency
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Blood Transfusions
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Severe Anemia
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Blood Clots
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Nervous or Mental Disorder
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Fainting Spells
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Convulsions or Epilepsy
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Bone or Joint Problems
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Back Trouble
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Neck Trouble
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Diabetes
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Thyroid Trouble
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Unexplained Fevers
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Do you use or have you used?
Tobacco
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Alcohol
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LSD or Amphetamines
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Narcotics
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