Pre-Anesthesia Medical History
PERSONAL INFORMATION
First
First Name
Last Name
E-mail
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Mobile
Phone Number
Weight
Height
Name of Surgeon/Dentist Practice?
What is the date of your surgery/procedure?
-
Month
-
Day
Year
Date
What time are you scheduled to arrive at medical office for procedure?
Hour Minutes
Please list any allergies to medications you may have:
Please list all medications you are taking:
If you are over the age of 70, please provide the name and phone number of your primary care provider.
CARDIOVASCULAR HISTORY Have you ever:
Been diagnosed with congestive heart failure?
Yes
No
Had a heart attack?
Yes
No
Had chest pain with exertion?
Yes
No
Had any type of heart surgery?
Yes
No
Experienced excessive shortness of breath with minimal exertion?
Yes
No
Seen a cardiologist for any reason?
Yes
No
Have you been prescribed nitroglycerin?
Yes
No
Been diagnosed with any heart disease?
Yes
No
Diagnosed with any disease of the the arteries or veins?
Yes
No
Have you had a stroke?
Yes
No
Illumination Anesthesia Medical History Form |970-703-5440 | illuminationanesthesia@gmail.com
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Have you been diagnosed with dysrhythmia?
Yes
No
If you regularly see a cardiologist, please provide thier name and phone number.
If you answered yes to any of these, please explain. If applicable, provide approximate dates for diagnosis, tests or surgeries
DASI Score (Duke Activity Status Index- a tool for estimating cardiovascular risk): In the past three months have you been able to?
Walk indoors, such as around your home?
Yes
No
Perform light housework such as dishes, dusting or laundry?
Yes
No
Take care of yourself(eating, bathing, dressing, toileting)?
Yes
No
Run a short distance?
Yes
No
Walk 1-2 blocks on level ground?
Yes
No
Engage in sexual relations?
Yes
No
Climb flight of stairs or walk up a hill?
Yes
No
Engage in strenuous activities such as running, swimming, biking, skiing, basketball?
Yes
No
Do yard work such as raking, weeding, or pushing a mower?
Yes
No
Participate in recreational activites such as golf, bowling, dance?
Yes
No
PULMONARY HISTORY. Have you ever:
Been diagnosed with COPD or asthma?
Yes
No
Smoked tobacco or marijuana regularly for more than a year?
Yes
No
Been diagnosed with pulmonary hypertension?
Yes
No
Been prescribed inhalers?
Yes
No
In the last 6 weeks, had a respiratory infection?
Yes
No
Illumination Anesthesia Medical History Form |970-703-5440 | illuminationanesthesia@gmail.com
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ILLUMINATION ANESTHESIA
If answered YES to any of these, please provide details about your condition by describing hospitalizations, treatments and symptoms.
Long Text
SLEEP APNEA ASSESMENT TOOL (STOPBANG):
Have you been diagnosed with sleep apnea?
Yes
No
Do you use a CPAP machine?
Yes
No
Do you snore loudly or have you been told loudly?
Yes
No
Have you been diagnosed with sleep apnea?
Yes
No
Have you been observed to stop breathing for a moment while you sleep at night?
Yes
No
Do you have, or are you being treated for, high blood pressure?
Yes
No
Do you often feel tired, fatigued or sleepy during the daytime?
Yes
No
Are you taking any GLP1 agonist medications (like Ozempic, or medication ending in 'glutide').
Yes
No
If you are taking a GLP1 you must not take for 7+ days prior to prior to procedure. Do you agree?
Yes
No
Are you taking any SGLT-2 medications like jardiance (empagliflozin) or other medications ending in 'ozin'?
Yes
No
If you are taking a SGLT-2 medication you must not take for 3+ days prior to prior to procedure. Do you agree?
Yes
No
Illumination Anesthesia Medical History Form | 970-703-5440 | illuminationanesthesia@gmail.com
ILLUMINATIONANESTHESIA
Have you ever been diagnosed with a blood clot in an artery or vein, or problems with bleeding excessively?
Yes
No
Do you have kidney or liver disease?
Yes
No
Have you ever had surgery on or through your nasal sinuses? If so, please describe.
Have you ever had a serious complication from anesthesia? If so, please describe.
Please use this box to describe any other conditions or diseases relevant to your health. Conditions such as liver or kidney disease, diabetes, thyroid problems, bleeding or blood clotting issues, previous cancer, chemo, or radiation, uncontrolled heartburn/reflux/GERD, or any other disease processes not
Illumination Anesthesia Medical History Form |970-703-5440 | illuminationanesthesia@gmail.com
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previously covered in the other questions on this form.
Do you have other aspects of your history you feel are important for us to know prior to safely performing an anesthetic?
Yes
No
If applicable: Are you pregnant or is there a chance you're pregnant?
Yes
No
EMERGENCY CONTACT DETAILS
Contact Person 1
Relationship
Contact Number
Contact Person 2
Relationship
Contact Number
Medical Consent
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Illumination Anesthesia Medical History Form |970-703-5440 | illuminationanesthesia@gmail.com
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