Anesthesia History Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
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 use Marijuana or other THC/CBD products or recreational drugs?
*
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
Chronic Lung Disease
Emphysema
Sleep Apnea
Difficulty Opening Mouth
Difficulty Swallowing
Chronic Acid Reflux
Mitral Valve Prolapse
Congestive Heart Failure
Artificial Heart Valve
Irregular Heartbeat
Angina
Heart attack
High Blood Pressure
Swelling Of Lower Legs
Poor Exercise Ability
Intestinal Disorders
Stomach Ulcer Disease
Stroke
Seizure Disorder
Muscle Disease/Disorders
Cancer
Nerve Injury
Easy Bruising/Bleeding
Anemia
Diabetes
Glaucoma
Thyroid Disease
Liver Disease
Hepatitis
Kidney Disease
Chronic Pain
History of DVTs
None
If you have selected any of the above health conditions, please explain:
*
Preferred Pharmacy:
*
Pharmacy Phone Number:
*
-
Area Code
Phone Number
Patient Signature
*
Clear
DateTime
*
Submit
Should be Empty: