Pre-operative questionnaire

Your name *

First Name

Last Name

Your date of birth *

MM

DD

YYYY

Please tick all statements below that apply to you:

I have had a heart attack, or had a stent or bypass operation.

I see a cardiologist.

I get chest pain or shortness of breath with exertion.

I have have significant lung issues.

I have bleeding tendencies.

I have significant liver or kidney issues.

I am diabetic.