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PRE-PERFUSION FORM 

Do you have any allergies or allergic reactions?
Have you recently consumed excessive amounts of alcohol?
Do you have (or have you had) any heart or vascular problems?
If yes, please give details :
Do you (already) have respiratory problems?
If yes, please give details :
Do you have (or have you ever had) any neurological or psychiatric problems?
If yes, please give details :
Do you have any bone, joint or spinal problems?
If yes, please give details :
Do you (already) have urinary problems?
If yes, please give details :
Do you have (or have you ever had) abdominal or digestive problems?
If yes, please give details :
Do you have (or have you had) coagulation problems? Have you ever had a transfusion?
If yes, please give details
Are you diabetic or have endocrine problems?
If yes, please give details :
Êtes-vous ou avez-vous déjà été traité pour un cancer ?
Si oui
Avez-vous (déjà eu) des problèmes ophtalmologiques ?
If yes, please give details :
Have you ever had an allergic reaction or adverse reaction to a vitamin?
Have you ever had an allergic reaction or adverse reaction to anesthesia?
Are you pregnant or could you be pregnant?
Allaitez-vous en ce moment ?
Are you currently taking any medication?
Do you know of any contraindication to receiving an IV infusion for any reason whatsoever?
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