Patient Health History

Are you allergic to any one of the following?

Latex

Eggs/Soy products

Drugs (if yes, mention below)

Medical History

Have you ever had...

C.V.S.:

High blood pressure

Heart attack, chest pain, or irregular heart rate

Rheumatic fever, mitral valve prolapse

RESP:

Shortness of breath, hay fever, chronic cough

Lung disease (asthma, emphysema, bronchitis)

C.N.S.:

Migraine headaches, seizures, stroke, depression

GI & LIVER:

Acid reflux, hiatal hernia

Jaundice, hepatitis, or any liver disease

RENAL:

Kidney or bladder disease

ENDO:

Diabetes / Thyroid disorder

HEME:

Anemia, sickle cell, bleeding problems

Blood clots in legs or lungs

OTHER:

Other health / physical related conditions

If you answered yes to any of the above, please expand.

Surgical & Anesthetic History

Surgery requiring anesthesia

Complications or ill effects related to anesthesia

Blood relative with H/O anesthetic side effects

If you answered yes to any of the above, please expand.

Other Information

Do you have...

Head, back, or neck pain / joint limitation

Cold, flu, or fever

Do you wear glasses or contacts

Women only...

Last menstrual period

Possibility of pregnancy

Oral contraceptives

If you answered yes to any of the above, please expand.

Social History

Do you use...

Tobacco

If yes, how many packs per day for how many years?

Alcohol

If yes, how often, and how much?

Drugs

If yes, how often and which drug?

Medications

Please write down any medications. Including dosage and frequency.

All of the information on this form is accurate to the best of my knowledge.

Your Signature

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