Pre-Surgical Medical History Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Contact Number
Email
Address
Health Information
Height
Weight
Blood Type
Allergies
Current Medications
Past Surgeries / Hospitalizations
Medical History
Medical Problems (Check all that apply):
Diabetes
Hypertension
Heart Disease
Asthma
Stroke
Kidney Disease
Other
If Other, please specify:
Anesthesia History
Have you or any family member had problems with anesthesia?
No
Yes
If yes, please describe: