When was the last time you had anything to EAT? Date* Time AM PM *
When was the last time you had anything to DRINK? Date* Time AM PM *
RELEVANT MEDICAL/SURGICAL HISTORY (Please tick eithier YES or NO)
If yes to any of the above, please provide details:
Blood thinning drugs Yes No * Name First Name* Last Name* Last taken: Date* Blood Results PT/INR * Platelets *