Anesthesia History Form
Date of Birth
Please complete this field if you would like a copy of your signed forms.
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?
Do you smoke?
If you smoke, how much?
Do you use Marijuana or other THC/CBD products or recreational drugs?
Do you drink alcoholic beverages?
If so, how many drinks per week?
Have you had any lab work or EKG within the last 6 months?
Are you or could you be pregnant?
Date of last menstrual period?
Have you had a fever, an infection, or have you taken antibiotics within the last two weeks?
Please select any health conditions that you have:
Chronic Lung Disease
Difficulty Opening Mouth
Chronic Acid Reflux
Mitral Valve Prolapse
Congestive Heart Failure
Artificial Heart Valve
High Blood Pressure
Swelling Of Lower Legs
Poor Exercise Ability
Stomach Ulcer Disease
History of DVTs
If you have selected any of the above health conditions, please explain:
Pharmacy Phone Number:
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