High blood pressure? Yes No

Heart Problems Yes No

Specify Heart Problems Heart murmur
Irregular heart beat

Pacemaker? Yes No

AICD Yes No

AICD Manufacturer / Representative Phone#

Heart Stents? Yes No

How many stents?

Heart Valves? Yes No

Angina? Yes No

Heart Attack? Yes No

When did you have heart attack?

Heart Failure Yes No

Heart Surgery Yes No

Specify heart surgery

Do you have a cardiologist? Yes No

Cardiologist name and phone

Cancer? Yes No

Asthma Yes No

What are your symptoms of a flair up?

Pneumonia? Yes No

COPD? Yes No

Can you walk up a flight of stairs? Yes No

Home oxygen use? Yes No

How much oxygen do you use?

Recent Cough/Cold/Flu (past 2 weeks)? Yes No

Sleep apnea? Yes No

Do you use CPAP?

Do you smoke? Yes No

Medical Implants? (include pins, screws etc.) Yes No

Diabetes? Insulin
Oral Agent
Diet Controlled

Kidney Problems? Yes No

Specify kidney problems

Liver Problems? Yes No

Specify Liver Problems

Thyroid Disease? Yes No

Specify Thyroid Disease

Acid reflux? Yes No

Ulcers? Yes No

Hiatal Hernia Yes No

Do you drink alcohol? Yes No

Stroke? Yes No

Specify when did you have your stroke and do you have any residual deficits (speech, difficulty swallowing, weakness, etc.)

Seizure? Yes No

Specify, include treatment and date of last seizure

Depression? Yes No

Anxiety Yes No

Mental Illness Yes No

Specify mental illness

ADD or ADHD Yes No

Autoimmune Disease? Yes No

Specify autoimmune disease

Bleeding or clotting (you or blood relative) Yes No

Specify bleeding or clotting problems

Anemia? Yes No

Sickle cell disease or trait? Yes No

HIV? Yes No

Hepatitis A B C

Last time you took blood thinners

Date of LMP (if applicable) ...

Allergies: Drug, Food, Latex, Environmental? (include reactions)

Medications? (OTC, ASA, Herbal Supplements, Vitamins, Inhalers) - specify douse, route and frequency.

Previous Surgeries (specify and include year)

Do you or blood relative have adverse reactions to anesthesia? Yes No

Specify reactions to anesthesia

Language Issues? Yes No

Specify language issues

Comments / Other information

Do you have Advanced Directive? Yes No

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