Surgeon:   
Personal Physician:

Planned Surgery:

Latex Sensitivity Questionnaire:

Allergies

1.    2.    

3.   4.

5.   6.

Current Medications:  Include Dosage and Frequency

1.    2.    

3.   4.

5.   6.

7.    8.

9.

Previous Surgeries/Hospitalizations:

Anesthesia History:

Select One Yes No Have you ever had problems with Anesthesia?

Select One Yes No History of high Temperatures with Anesthesia?

Select One Yes No Had trouble putting a breathing tube in your throat?

Gastrointestinal:   Do you have?

Select One Yes No Ulcers or stomach problems (nausea or vomiting)   

Select One Yes No Liver problems or jaundice

Select One Yes No Hiatal Hernia / Reflux             

Cardiovascular:    Do you have?

Select One Yes No High blood pressure

Select One Yes No Racing or skipped beats

Select One Yes No Chest pain or tightness

Select One Yes No Heart Attack

Select One Yes No Bypass Surgery

Select One Yes No High Cholesterol

Select One Yes No Shortness of breath 

Select One Yes No Swollen feet or ankles             

Select One Yes No Stroke

Select One Yes No Unconsciousness

Select One Yes No Pacemaker / AICD  

Do you do any of the following:        

Select One Yes No Smoke        

Select One Yes No Alcohol       

Select One Yes No Street Drugs

Respiratory System:  Do you have?

Select One Yes No Asthma/ Sinus Problems

Select One Yes No Emphysema

Select One Yes No Chronic or Frequent Cough     

Select One Yes No Abnormal Chest X-Ray           

Select One Yes No Apnea

Renal System: Do you have?

Select One Yes No Renal/Kidney problems

Gynecological:   Do you have?

Select One N/A Yes No Are you Postmenopausal

Select One NA Yes No Regular Periods

Select One NA Yes No Pregnant/Breastfeeding

Select One NA Yes No Last Period

Select One N/A Yes No Tubal / Hysterectomy

Miscellaneous:    Do you have?

Select One Yes No Diabetes

Select One Yes No Thyroid or goiter problems

Select One Yes No Arthritis

Select One Yes No Bleeding or blood problems

Select One Yes No Glaucoma

Select One Yes No Seizures / Convulsions

Select One Yes No Prostrate Problems

Select One Yes No Do you take blood thinners?

Select One Yes No Immune System Disorders? (i.e. HIV, Cancer)

Select One Yes No Hepatitis

Select One Yes No Use over the counter herbal medications
                   Date last Taken:

Height:       

Weight:      

Daytime Phone number for contact: