Pre-Operative Medical History Form

Emphysema:(Required)
Asthma:(Required)
High Blood Pressure:(Required)
Chest Pain / Angina:(Required)
Heart Palpitations:(Required)
Anemia:(Required)
Hiatal Hernia / Ulcer:(Required)
Liver Issues / Hepatitis:(Required)
Back / Neck Pain or Injury:(Required)
Sciatica:(Required)
Epilepsy / Seizures:(Required)
Stroke:(Required)
Thyroid Disease:(Required)
Diabetes:(Required)
Low Blood Sugar:(Required)
Sleep Apnea:(Required)
Nausea with Anesthesia:(Required)
Blood Clot / DVT / PE / Bleeding Disorder:(Required)
Do you currently have a cold?(Required)
Have you ever had COVID-19?(Required)
Did you have the COVID-19 Vaccine?(Required)
Are you or have you ever been a smoker?(Required)
Do you vape?(Required)
Do you drink alcohol?(Required)
Do you use any marijuana products?(Required)
Have you had a blood transfusion?(Required)
Do you take aspirin or any blood thinners?(Required)
Do you have dentures, caps, loose or chipped teeth?(Required)
Do you take or have you taken any addicting drugs?(Required)
Have you or a family member had an unusual reaction to anesthesia?(Required)

For female patients:

Are you currently pregnant or breastfeeding?
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