Anesthesia History Form

Anesthesia History Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Sex: *
Height *
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? *
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 *
Should be Empty: