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2. Have you ever had an allergic reaction to Bactine®, benzalkonium chloride, or other topical antiseptics?

Yes

No

3. Do you currently have broken skin, open wounds, or skin infections at the area where the topical will be applied?

Yes

No

4. Do you have a history of severe eczema, psoriasis, or other skin conditions at the area to be treated?

Yes

No

5. Do you have any heart rhythm problems (arrhythmias) or heart block?

Yes

No

6. Do you have severe liver disease?

Yes

No

7. Have you ever experienced seizures related to medications or anesthetics?

Yes

No

8. Are you currently pregnant or breastfeeding?

Yes

No

9. Are you currently taking any antiarrhythmic medications (such as amiodarone, mexiletine, quinidine)?

Yes

No

10. Are you currently taking any medications for seizures or nerve pain that your provider has warned may interact with anesthetics?

Yes

No

11. Have you ever fainted, felt dizzy, or had a severe reaction when using local anesthetics before?

Yes

No

12. Have you ever been told you have a condition called methemoglobinemia or a blood disorder affecting oxygen carrying capacity?

Yes

No

Topical Anesthetic / CQI Screening

User Information

Mailing Address

Section 1: Allergies / Sensitivities

Section 2: Skin Conditions / Open Wounds

Section 3: Medical History

Section 4: Medications / Substances

Section 5: Past Reactions / Complications