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Patient Information Form

Note: This form will not submit successfully unless all the fields have entries.

Patient Information:

You have been referred to our office for Anesthesia Services. Please provide us with your complete medical information. This will allow us to better understand your needs and therefore serve you best.

Last Name: First Name: Name Preference:

Street Address: City: State:Zip:

Date of Birth:Cell #: Home Phone #:

Email: Sex:Parent/Guardian:

General Dentist Name/Office:

General Dentist/Phone #: Physician/Phone #: Specialist/Phone #:

In Case of Emergency:

Name: Home/Phone #: Cell/Work Phone #:

Name: Home/Phone #: Cell/Work Phone #:

Medical History:

1. Have you ever been put under anesthesia before?If yes, for what type of procedure?

Where and When?

Did you experience any complications?

2. Have you ever had surgery?If yes, what type of surgery?

Where and When?

Did you experience any complications?

3. Have you ever been hospitalized?If yes, for what reason?

Where and When?

How many days?

4. Please check the box for any of the following conditions which may apply to you now or have applied to you in the past:

ADHD Depression High Blood Pressure
Anemia, Type Developmental Delay HIV
Angina Pectoris Diabetes Mitral Valve Prolapse
Anxiety Down Syndrome Reactive Airway Disease
Artificial Heart Valve Drug Addiction Recreational Drug/Alcohol Use
Artificial Joint Epilepsy or Seizures Sickle Cell Disease
Asthma Heart Attack Shunt
Autism Heart Disease Stroke
Bipolar Heart Murmur Thyroid Disease
Bleeding Disorder Heart Pacemaker, Defibrillator Tuberculosis
Cancer Heart Surgery Wheel Chair Bound
Cerebral Palsy Hepatitis, Type Other

5. Do you smoke cigarettes or use smokeless tobacco? If yes, how many packs per day?

6. Are you allergic to any medications such as local anesthetic, Penicillin, Erythromycin, Codiene, Aspirin, Sulfa, or any other medication?
If yes, please explain:

7. What medications are you currently taking?

Name of Medication Dosage Prescribed Reason

8. What is your current height and weight?

9. When was the last time you were sick with a cold, cough or fever?

10. Is there anything that we haven’t asked that you feel would be important for us to know? If yes, please explain: