Medical History form
Medical History form
Medical History form

Pre-Anesthesia Questionnaire
Patient name :
Date of surgery :
Physician name :
Medications including OTC & supplements :
Height :
Weight :
Primary Care Dr. :
Cardiologist :
Did you ever Smoke ? Yes
No
Use Alcohol or recreational drugs ? None
Occasional
Daily
Amount :
Past surgeries : T&A
Appendix
Gallbladder
Hernia
Hysterectomy
Other surgeries :
Have you or a blood relative ever had a problem with anesthesia : No
Yes
Daily Steroid Tx
Do you have a Prosthesis ? AICD
Pacemaker
Total Joint
Do you have any cultural or religious needs ?

Have you had any of the following?
Diabetes: IDDM NIDDM : Yes
No
High BP/Coronary Disease/Valve Problems,Cholesterol : Yes
No
Heart Problems/MVP/Heart Surgery/Stents/MI : Yes
No
Congestive heart failure : Yes
No
Irregular heart rhythm/palpitations : Yes
No
Stroke and/or weakness/numbness/TIA : Yes
No
Lung: Emphysema/COPD/Asthma/Bronchitis/Sleep Apnea/CPAP/O2 : Yes
No
Seizure/Convulsions : Yes
No
Muscle or Nerve Problems : Yes
No
Cancer : Yes
No
Kidney/Bladder/Prostate/Dialysis : Yes
No
Thyroid : Yes
No
Bleeding problems/Anemia : Yes
No
Liver: hepatitis, jaundice : Yes
No
Heartburn, acid reflux, hiatal hernia, ulcers,diviticulitis : Yes
No
Arthritis : Yes
No

Have you experienced any of the following lately?
Chest pain, discomfort or tightness in your chest, arm, neck or jaw ? Yes
No
Difficulty breathing while : Sitting
Walking short distances
Lying flat
Do you wake up at night while short of breath ? Yes
No
Dizzy spells or fainting ? Yes
No
Loose or chipped teeth, crowns/caps/dentures : Upper
Lower

Insurance Information

Please bring your insurance cards and drivers license with you on the day of surgery as we will need a copy of them.

Primary Insurance :
Name of Insured Person if other than patient :
Patient ID # :
Group ID # :
Secondary Insurance :
Name of Insured Person if other than patient :
Insured ID # :
Group ID # :

To be completed by Patient

Please bring insurance ID card on day of surgery.

Patient First Name :
Patient Last Name :
Patient Middle Initial :
Date of Birth :
Sex : Male
Female
Home Address :
City :
State :
Zip :
Is the Mailing Address different : Yes
No
Home Phone :
Cell Phone :
Emergence Phone :
Marital Status : Single
Married
Widowed
Divorced
Responsible Party if Patient is a minor :
Relationship to Patient : Mother
Father
Guardian
Other
Patient/Responsible Party Social Security # :
Employer :
Occupation :
Employer Address :
Employer City :
Employer State :
Employer Zip :
Work Phone # :
Spouse/Other Parent Name :
Spouse/Other Parent SS # :
Employer :
Occupation :
Employer Address :
Employer City :
Employer State :
Employer Zip :
Work Phone # :
Primary Care Physician :
Primary Care Physician Phone # :
Person(s) to Notify in Case of Emergency :
Address :
City :
State :
Zip :
Home Phone # :
Work Phone # :

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