Pre-Surgery Health Assessment Questionnaire
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Contact Number
Medical History
List any existing medical conditions
Allergies (medications, food, etc.)
Current Medications
Previous Surgeries (with year)
Problems with anesthesia in the past?
Yes
No
Lifestyle
Do you smoke?
Yes
No
Former smoker
Do you consume alcohol?
Yes
No
Occasionally
Other Relevant Information