Pre-Surgical Medical History Form
Patient Information
Full Name
Date of Birth
Sex
Female
Male
Other
Address
Phone Number
Email Address
Medical History
Allergies (medications, latex, foods, etc.)
Current Medications (include dosage and frequency)
Previous or Current Medical Conditions
Previous Surgeries or Hospitalizations
Family History of Medical Conditions
Lifestyle
Do you smoke?
No
Yes
Former Smoker
Do you consume alcohol?
No
Yes
Other Substance Use
Other Information
Are you currently pregnant?
No
Yes
N/A
Additional Notes or Concerns