Anesthesia Forms

Patient Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Any allergies to medications, foods, latex, adhesive tape or other substances?

Yes

No

Any personal complications with anesthesia?

Yes

No

Never had Anesthesia

Has anyone in the family had complications with anesthesia?

Yes

No

Unsure

Is the patient able to walk up a flight of stairs without taking a break?

Yes

No

Pregnant or planning to become pregnant?

Yes

No

Unsure

Smoke or use tobacco products

Yes

No

Consume more than four alcoholic drinks a week?

Yes

No

Use recreational drugs?

Yes

No

Has the patient ever been hospitalized?

Yes

No

Is the patient currently under the care of a PCP?

Yes

No

Please select all specialists in the patient's care

Cardiologist (Heart doctor)

Pulmonologist (Lung Doctor)

Neurologist

Nephrologist (Kidney Doctor)

Endocrinologist

Born Prematurely?

Yes

No

Down Syndrome (Trisomy 21)

Yes

No

Cerebral Palsy

Yes

No

Heart Failure

Yes

No

Irregular Heart Beats/Heart Murmurs

Yes

No

Heart Valve Concerns

Yes

No

Previous Heart Attack

Yes

No

Pacemaker/Defibrillator

Yes

No

Previous Cardiac Surgery

Yes

No

Heart Stents

Yes

No

Enlarge Tonsils

Yes

No

Shortness of Breath/Difficulty Breathing

Yes

No

Snore Heavily at Night

Yes

No

Require Frequent Naps to Feel Rested

Yes

No

Obstructive Sleep Apnea

Yes

No

Asthma

Yes

No

Chronic Obstructive Pulmonary Disease/Emphysema

Yes

No

Do You Require Supplemental Oxygen?

Yes

No

Pulmonary Embolism

Yes

No

Previous Stroke

Yes

No

Dementia/Alzheimer’s

Yes

No

Seizures or Epilepsy

Yes

No

ADHD or Autism

Yes

No

Depression

Yes

No

Anxiety

Yes

No

Liver Disease (Hepatitis, Cirrhosis)

Yes

No

Kidney Disease (Kidney Failure/Insufficiency, Kidney Stones)

Yes

No

Thyroid Disease (Hypothyroidism, Hyperthyroidism)

Yes

No

Diabetic

Yes

No

Muscle disorder (Hypotonia, Muscular Dystrophy, Contractures)

Yes

No

Acid Reflux

Yes

No

Intestinal Disease (Ulcer colitis, Chron’s Disease)

Yes

No

Blood Disorder (Anemia, Thalassemia, Sickle Cell)

Yes

No

Bleeding disorders (Von Willebrand’s, Hemophilia)

Yes

No

HIV or AIDS

Yes

No

Consent and Acknowledgment By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used to plan and provide safe anesthesia care. Withholding any information could jeopardize the patient’s safety.

First Name

Last Name