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| Patient Name* |
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| Chief Complaints* |
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| Physician* |
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| Physician Phone Number* |
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| Procedure* |
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| Patient Address* |
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| Patient Phone Number* |
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| County* |
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| Date of Birth* |
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| Male or Female* |
Male Female |
| Age* |
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| Weight (in pounds)* |
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| Height* |
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| SSN* |
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| Primary Insurance* |
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| Plan Number* |
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| Claim Address* |
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| Insured* |
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| Insured SSN* |
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| Employer |
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| Employer Phone Number |
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| Employer Address |
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| Secondary Insurance |
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| Plan Number |
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| Claim Address |
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| Insured |
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| Insured SSN |
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| Employer |
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| Employer Phone Number |
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| List all allergies, especially to medications.* |
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List all prescription medications you are currently taking (include inhalers and patches).*
For each, include: medication name, amount/dosage, number of times per day |
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List all over-the-counter medications, herbal medications and supplements that you are currently taking.*
For each, include: medication name, amount/dosage, number of times per day |
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| List all operations and anesthetics (spinal or general) you have had and dates performed.* |
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For the questions below, briefly explain all yes answers. |
Have you or any family member ever had a problem with anesthesia or surgery?* |
| Yes
No
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Have you ever had a heart attack?* |
| Yes
No
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Have you ever had Congestive Heart Failure or any other heart problem?* |
| Yes
No
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Have you ever had angina or chest pain?* |
| Yes
No
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Do you experience shortness of breath?* |
| Yes
No
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Do you have difficulty walking up more than one flight of stairs? Why?* |
| Yes
No
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Have you ever had hypertension (high blood pressure)?* |
| Yes
No
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Have you ever been diagnosed as having an irregular (arrhythmia), slow, or fast heart beat (pulse)?* |
| Yes
No
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Do you have a pacemaker, permanent IV line?* |
| Yes
No
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Have you ever been diagnosed as having emphysema, asthma, or tuberculosis?* |
| Yes
No
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Do you smoke? If yes, How many years, how many packs per day? If you have quit, how long ago?* |
| Yes
No
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Have you ever had a stroke?* |
| Yes
No
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Have you ever had polio, paralysis, or multiple sclerosis?* |
| Yes
No
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Have you ever had convulsions/epilepsy?* |
| Yes
No
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Have you ever been diagnosed as having a hiatal hernia?* |
| Yes
No
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Have you ever had kidney or liver problems? Hepatitis?* |
| Yes
No
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Do you have diabetes? How long?* |
| Yes
No
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Have you ever had thyroid problems?* |
| Yes
No
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Have you ever had ulcers or other stomach disorders?* |
| Yes
No
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Do you have any muscle or nerve disease?* |
| Yes
No
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Do you or any of your family have sickle cell trait?* |
| Yes
No
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Have you ever had phlebitis (blood clots)?* |
| Yes
No
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Do you have bleeding tendencies?* |
| Yes
No
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Have you ever had a blood transfusion?* |
| Yes
No
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Do you have rheumatoid arthritis?* |
| Yes
No
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Have you ever had eye problems/glaucoma/cataracts?* |
| Yes
No
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Do you drink alcohol? How much, how often?* |
| Yes
No
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Have you used marijuana, cocaine, or other "street" drugs in the past week? Which ones?*
If yes, please discontinue use 72 hours prior to surgery. |
| Yes
No
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Do you have any sexually transmitted diseases?* |
| Yes
No
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Are you pregnant now?* |
| Yes
No
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Do you have dentures, capped, loose, or chipped teeth?* |
| Yes
No
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Do you have any oral piercings, (such as studs or rings) in your tongue or lip?* |
| Yes
No
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Do you wear contact lenses?* |
| Yes
No
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Comments on any medical condition not covered above: |
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