Pre-Anesthesia Health History

In order to provide us with your health history, please click here for the PDF version, or fill out and submit the form below. Thank you!

    Patient Name

  • Patient Information

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    If yes, please Explain:

  • If yes, please list reason, dates of hospitalization, and at which hospital they were admitted:

  • If yes, please list reason, date, and at which hospital they were seen:

  • If yes, please list what specialty and when they were last seen:

  • If yes, please list ALL medications, supplements, inhalers, and medications through a nebulizer:






















  • If yes, type of allergy?

    If yes to any of the above, please list reaction(s):
  • Please list any additional food and/or Medication allergies:















  • Please select any / all that apply to patient:






    ( )



    Other:










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    Other:


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    Other:


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    Result (A1C):



    Other:






    Other:






    Other:









    Other:






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    Other:







    If yes, type:

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    Other:







    Other:

  • If yes, please explain:


  • MEDICAL RECORDS RELEASE DISCLOSURE:

    I acknowledge, and hereby consent to the release of all medical records to Advanced Specialty Anesthesia. Medical information will be requested only if pertinent to planning and care associated with requested anesthesia services for mine or my child’s upcoming dental or surgical procedure. The following are authorized to disclose information:

  • Patient Name

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    Primary Care Physician:

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    Facility Name:

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    Specialist Physician:

    - -

    Facility Name:

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    Specialist Physician:

    - -

    Facility Name:

    - -






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Office: (785) 856-6170 | Fax: (785) 422-5477

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