• New Patient Preoperative Questionnaire

    Please review and answer these questions regarding your medical history. Understand that this information must be as complete as possible to ensure that you are receiving the proper anesthetic care for your individual needs.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Daily medications

    Including all of the following: Prescriptions, Pain patches, Over-the-counter, Inhalers, Vitamin/Herbal, and Dietary Supplements.
  • Click below to skip this section (daily medications)
  • List all medications. Use the plus sign to add a new medication to the form.

  • Allergies

    List all allergies to Medications, Foods, and Other Substances such as Latex, Rubber, Shellfish, Iodine, Tape.
  • List all allergies.

  • Tobacco, Alcohol, Illicit drugs

    Check all that apply
  • Alcohol Consumption
  • Have you ever used tobacco/nicotine?*
  • Check each box that applies if you have used these additional substances:

  • Anesthetic History

  • Cardiac History

  • Check all heart conditions that apply
  • Are you able to go up 2 flights of stairs or walk 2 blocks without chest pain or shortness of breath?
  • Angina/ chest pain
  • Aneurysm or vena cava surgical clips?

  • Renal & Endocrine History

  • Diabetes:
  • Thyroid History
  • Kidney History

  • Pulmonary History

  • Check all breathing conditions that apply
  • I have had COVID or other respiratory infection
  • Emphysema/COPD
  • Sleep Apnea

  • Musculoskeletal & Neurological History

  • Check all skeletal conditions that apply
  • Have you had a stroke?
  • History of Migraine Headaches
  • Do you have Epilepsy?
  • Are you on anticonvulsants?
  • Do you have brain trauma/damage?
  • Do you have a spinal nerve stimulator?
  • Do you have an implanted drug delivery system?
  • Do you have surgical implants?
  • Check all neurological conditions that apply

  • Gastrointestinal & Hepatic History

  • Check all gastrointestinal conditions that apply
  • Reflux

  • Hematologic History

  • Check all blood conditions that apply

  • Psychiatric History

  • Check all conditions that apply

  • Immunodeficiency History

  • Check all immune system conditions that apply

  • Pain Therapy

  • Check all pain diagnoses that apply*
  • Where is your pain primarily located?*
  • How would you describe your pain?*
  • Pain INCREASES with*
  • Pain DECREASES with*

  • Other Medical History

  • Are you pregnant?
  • Breastfeeding?
  • Check all other conditions that apply
  • Should be Empty: