Pre-Anesthesia Health History

    Patient Information

    Please let us know the patient name and email address.


    Allergy Information

    Please fill out the patient allergy list below.

    Are you ALLERGIC to anything?
    YesNo

    Allergy List


    Pre-Existing Conditions

    Please check any below that pertain to you.

    Heart Conditions

    Irregular Heart BeatHeart DiseaseHeart Valve DiseaseMitrial Valve Prolapse

    Heart AttackAnginaChest PainCongestive Heart Failure (CHF)PacemakerFainting

    High Blood PressureDeep Vein Thrombosis (DVT) Active

    If so, when?


    Cold/Flu

    ColdCoughAsthma (Wheezing)

    Lung Conditions

    Lung DiseaseDifficulty BreathingSleep Apnea

    Smokers

    Tobacco

    How much, How long? Quit?


    Neurological

    Frequent HeadachesStrokeNeurological Disease

    Nervous DisorderSeizures

    Pre-Existing Conditions

    DiabetesThyroid Disease

    Kidney DiseaseLiver Disease

    Infectious Disease

    HepatitisHIVTBOther


    Gastrointestinal Conditions

    HeartburnGastritisEsophageal RefluxHiatal HerniaUlcer

    Alcohol

    Drink Alcoholic Beverages

    How much, How long?



    Previous Surgeries

    Please fill out the information below.

    Have you had previous surgeries? YesNo

    Surgery List


    Additional Information

    Please fill out the information below.

    Can you climb a flight of stairs?
    YesNo

    How Many?

    1234+

    Have you ever had problems with anesthetics?
    YesNo

    Please check all that apply

    NauseaVomitingMalifnantHyperthermia

    Has anyone in your family had unusual reactions to anesthetics?
    YesNo

    Drug Use? YesNo


    Check all that apply

    ArthritisRheumatism


    Difficulty Opening MouthMoving Neck

    DenturesChippedLoose TeethSpecial Dental Work

    BleedingBlood TransfusionBruisingSickle CellClotting Problems

    Contact LensesGlaucoma

    If you are not here related to a pregnancy are you possibly PREGNANT?
    YesNo


    NOTE: IF YOU HAVE BEEN TAKING ANY ILLICIT (STREET) DRUGS, PLEASE TELL THE ANESTHESIOLOGIST. THIS IS IMPORTANT FOR YOUR SAFETY.

    No Medications Taken

    Is there anything else we should know?


    Signature

    Patient Signature:

    Date:

    Scripps Mercy Surgery Pavilion

    Top Quality Surgeons