Name:      

E-Mail:

Birthdate:
Date of Surgery: 

Surgeon:   

Personal Physician:

Planned Surgery:             

Age:    Weight:

Allergies:

Other Allergies (i.e. Foods, Pollen)

Current Medications Child is Taking:

Previous Surgeries: (Any problems with Anesthesia during these Surgeries)

Previous Hospitalizations:

Medical History Review

History of:

Select One Yes No Asthma/Respiratory problems Frequent Colds/ Lung Problems

Select One Yes No Diabetes

Select One Yes No Seizures

Select One Yes No Cardiac Problems

Select One Yes No Muscular Problems

Select One Yes No Developmental Delays

Select One Yes No GI Problems

Select One Yes No Sickle Cell Disease or Trait

Select Any None Diarrhea Cough Vomiting Rashes Recent (Select any that apply)

Select One Yes No Has Menses started

Select One Yes No Immunization Status Up to Date (Bring Immunization Card to be copied for chart)

Who is the Legal Guardian of the Child? 

Does the Child Have a Nickname? 

Daytime Phone number for contact: