Anesthesia Patient Preoperative Questionnaire

New Patient Preoperative Questionnaire

Please review and answer these questions regarding your medical history. Understand that this information must be as complete as possible to ensure that you are receiving the proper anesthetic care for your individual needs.
Dental Provider*
Date of Procedure*

MonthDayYear
Date
Patient Name*

First NameLast Name

Daily medications

Including all of the following: Prescription, Over-the-counter, Inhalers, Vitamin/Herbal and Dietary Supplements.
Click below to skip this section (daily medications)

I do not take any medications dailyI only take over-the-counter medicine such as vitamins
List all medications. Use the plus sign to add a new medication to the form.
Allergies

List all allergies to Medications, Foods, and Other Substances such as Latex, Rubber, Shellfish, Iodine, Tape.
List all allergies.

Hematologic History
Click here to skip this section (hematologic history)

I do not have any blood-based conditions
Check all blood conditions that apply

AnemiaSickle cell diseaseSickle cell traitHistory of blood clotsDVTPEBleeding problems/Hemophelia

Psychiatric History
Click here to skip this section (psychiatric history)

I do not have any history of mental illness
Check all conditions that apply

AnxietyDepressionADHDPTSDBipolar disorderOther

Immunodeficiency History
Click here to skip this section (immunodeficiency history)

I do not have a compromised immune system
Check all immune system conditions that apply

HIVCancerChemotherapyRadiationLupusOther

Other Medical History
Last Menstrual Period*

Not applicablePeriod Start Date
Check all other conditions that apply

GlaucomaHearing LossVision loss or blindnessOther
Please explain any illness, complaints, or hospitalizations in the last six (6) months:
By providing my digital signature, I acknowledge that I have read and answered the previous questions truthfully.

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New Patient Preoperative Questionnaire