Anesthesia History Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex:
*
Female
Male
Height
*
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7"0"
Weight
*
Patient Email:
Please complete this field if you would like a copy of your signed forms.
Surgery Planned:
*
List Any Medication or Food ALLERGIES:
*
List all medications, including herbal supplements, and over the counter medications you currently take, or have taken in the last 6 months:
*
List ALL surgical procedures you have undergone at any time in the past:
*
Have you had any reactions, allergic or otherwise, to the medications you received in the past during surgical procedures?
*
Have you ever had a personal history of Malignant Hyperthermia, a muscle or neuromuscular disorder, high temperature following exercise, dark or chocolate colored urine, or fever following general anesthesia? If yes, please explain.
*
Is there a family history of allergic reactions or fevers during anesthesia?
*
Yes
No
Do you smoke?
*
Yes
No
If you smoke, how much?
Do you drink alcoholic beverages?
*
Yes
No
If so, how many drinks per week?
Have you had any lab work or EKG within the last 6 months?
*
Yes
No
Are you or could you be pregnant?
*
Yes
No
Date of last menstrual period?
Have you had a fever, an infection, or have you taken antibiotics within the last two weeks?
*
Yes
No
Please select any health conditions that you have:
*
Asthma
Heart Attack
Mitral Valve Prolapse
Swelling of Lower Leg
Difficulty Opening Mouth
Difficulty Swallowing
Intestinal Disorders
Easy Bruising/Bleeding
Nerve Injury
Anemia
Chronic Lung Disease
Emphysema
Angina
Congestive Heart Failure
Poor Exercise Ability
Stomach Ulcer Disease
High Blood Pressure
Kidney Disease
Hepatitis
Seizure Disorder
Muscle Disease/Disorders
Cancer
Sleep Apnea
Artificial Heart Valve
Irregular Heart Beat
Chronic Pain
Chronic Acid Reflux
Stroke
Liver Disease
Glaucoma
Diabetes
Thyroid Disease
History of DVTs
NONE
Preferred Pharmacy:
*
Pharmacy Phone Number:
*
-
Area Code
Phone Number
Patient Signature
*
Clear
DateTime
*
Submit
Should be Empty: