Anesthesia Day-Of Preoperative Assessment
Patient Name
Date
-
Month
-
Day
Year
Date
ALLERGIES/MEDICATION ALLERGIES
NKDA
No food allergies
Soy
Eggs
LATEX ALLERGY
No
Yes
HISTORY OF ANESTHESIA COMPLICATIONS
Patient
No
Yes
Blood Relatives
No
Yes
Other
SOCIAL
ETOH USE
No
Yes
ILLICIT DRUG USE
No
Yes
# DRINKS
Frequent
Occasional
Other
TOBACCO USE
No
Yes
Smokeless
Quit
Other
PAIN
Duration / intensity
Acute
Chronic
Other
Location
OTHER
Conditions / past procedures
Pregnant
Nursing
Patient States Not Pregnant
Bilateral Tubal Ligation
Hysterectomy
Vasectomy
Abstention
Other
Pregnancy Test Name
Lot Number
Expiration Date
Result
Positive
Negative
Recent URI
No
Yes
Other
Hiatal hernia / gastric reflux
No
Yes
Other conditions
Obesity / less than 90% ideal body weight
Immunosuppressed / steroids
Cancer/chemo/radiation
Anemia / bleeding disorders
Other
Pediatric pts immunizations up to date
No
Yes
Preparatory steps for anesthesia:
Swish with water
Contact lenses out
I have not had anything to eat or drink for 6 hours prior to my dental treatment
I have made arrangements for someone to drive me home after my dental treatment
There will be a responsible adult to take care of me for 24 hours after my dental surgery
Submit
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