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Patient History Form

Give us some basic information about yourself
Tell us your height and weight
Tell us about your appointment
Emergency Contact Information
Tell us about your living situation
Tell us about your health habits
Tell us about your history with Anesthesia

Please indicate your past medical experiences and the year, including: past surgery, anesthesia, hospitalization, medical history, dental, childbirth

Year Experience
Tell us about your allergy history
Allergies and adverse effects: (drug, food, environment, contact)
Reaction
Tell us about your medications
Medication
Dose
Why Taken
Taken How Often?
How Taken?
Review of Systems
Vision
Blindness
Hearing Aid
Dentures:
Oral Information:
Nose/Throat
Heart
Cirulation
Endocrine
Skin
Psychosocial
Bones/Muscles
Lung
Gastrointestinal
Blood
Nervous System
Cancer
Kideny / Bladder / Prostate
Female Reproductive
Pain Information
Family History

Has any blood relative had any of the following? (Check all that apply)

If you are finished

Please submit your information now. Thank you for completing this form.

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