Pre-Anesthesia Medical History Form
Personal Information
Full Name
Date of Birth
Age
Weight (kg)
Height (cm)
Contact Information
Phone Number
Emergency Contact Name
Emergency Contact Phone
Medical History
List any past surgeries
List current medical conditions
List any allergies (medications, foods, latex, etc.)
Current Medications
Please list all medications you are currently taking
Lifestyle
Smoker
Alcohol Use
Recreational Drugs
Anesthesia History
Have you had problems with anesthesia before?
Yes
No
If yes, please describe
Family History
Has anyone in your family had problems with anesthesia?
Yes
No
If yes, please describe
Other Information
Is there any other information the anesthesia team should know?