Pre-Anesthesia Health History

First * M.I. Last *

Date of Birth * / MM / DD YYYY

Height * FT INCHES Weight * LBS

SURGICAL/ANESTHESIA HISTORY * Yes (please list below) None

Surgery

Date / MM / DD YYYY

Surgery

Date / MM / DD YYYY

Surgery

Date / MM / DD YYYY

Is there any Family History of Anesthesia Complications? * Yes No
If yes, please Explain:

Has the patient ever been hospitalized? * Yes No
If yes, please list reason, dates of hospitalization, and at which hospital they were admitted:

Has the patient visited the ER in the last 30 days? * Yes No
If yes, please list reason, date, and at which hospital they were seen:

Has the patient seen a specialist for any reason? * Yes No
If yes, please list what specialty and when they were last seen:

Does the patient take any medications? * Yes No
If yes, please list ALL medications, supplements, inhalers, and medications through a nebulizer:

Medication:

Reason:

Medication:

Reason:

Medication:

Reason:

Medication:

Reason:

Additional Medications:

Does the patient have any allergies? * Yes No
If yes, type of allergy?
Soy Latex Eggs Iodine Peanuts Tree Nuts
If yes to any of the above, please list reaction(s):

Please list any additional food and/or Medication allergies:

Allergy:

Reaction:

Allergy:

Reaction:

Allergy:

Reaction:

Has the patient been prescribed an epipen? * Yes No

Please select any / all that apply to patient:

NEUROLOGIC (BRAIN): None
Seizures If yes, date of last seizure:
/ MM / DD YYYY
Paralysis/Muscle Weakness
Hydrocephalus
Fainting/Dizziness
Other:

ENDOCRINE: None
Diabetes If yes, date of last A1C:
/ MM / DD YYYY

Result (A1C):
Thyroid Disorder
Adrenal Disorder
Metabolic Disorder
Other:

PSYCHOSOCIAL: None
Developmental Delay
Autism
Intellectual Disability/MR
ADD/ADHD
Depression/Anxiety
Other:

EAR, NOSE, THROAT: None
Enlarged Tonsils/Adenoids
Sleep Apnea (pauses or gasps in breathing during sleep)
Recent Strep or Throat infection
Snoring
Difficulty Swallowing
Other:

STOMACH, LIVER, KIDNEYS: None
Acid Reflux/GERD
Chronic Nausea and/or Vomiting
Hiatal Hernia
Feeding Tube/PEG tube
Hepatitis A, B, or C
Chronic Kidney Disease
Fatty Liver Disease
Cirrhosis of the Liver
Other:

MUSCULOSKELETAL: None
Cerebral Palsy
Scoliosis
Arthritis
Muscular Dystrophy
CVA/Stroke/TIA If yes, date of occurrence:
/ MM / DD YYYY
Chronic Headaches/Migraines
Other:

BLOOD DISORDERS: None
Anemia
Bleeding/Clotting Problems (including family history)
Easy Bruising
Sickle Cell
HIV/AIDS
Cancer
If yes, type:
If yes, date of diagnosis:
/ MM / DD YYYY

Other:

GENETIC DISORDERS: None
Angleman’s Syndrome
Fragile X
Down’s Syndrome
DiGeorge Syndrome
Wolf-Parkinson-White Syndrome
Turner’s / Klinefelter Syndrome
Other:

Are there any other diagnoses or pertinent medical information you feel we need to be aware of?
If yes, please explain:

Patient Name

First * M.I. Last *

Date of Birth * / MM / DD YYYY

Primary Care Physician:

Phone Number: - -

Facility Name:

Fax Number: - -

Specialist Physician:

Phone Number: - -

Facility Name:

Fax Number: - -

Patient/Parent Signature (please type your full name to sign this form): *

Print Name/Relationship to Patient: *

Date * / MM / DD YYYY

Patient Name

Patient Information

MEDICAL RECORDS RELEASE DISCLOSURE:

Patient Name

PROFESSIONAL DISTINCTIONS

FORMS

ADDITIONAL INFORMATION