Summit Anesthesia
PATIENTS
PROFESSIONALS
PAYMENT & FORMS
CONTACT US
OUR DOCTORS
MEDICAL HISTORY QUESTIONNAIRE
Please take time to carefully fill out this questionnaire.
1
Step 1
Patient Information
2
Step 2
Medical History
3
Step 3
Billing Payment
Step 1 Patient Information
*Patient's First Name
*Patient's Last Name
*Patient's Address
*Patient's City
*Patient's State
Select a State...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Patient's Zip
*Patient's Primary Phone
Patient's Alternative Phone
*Patient's Date of Birth
*Patient's Age
*Patient's Weight
lb
Patient's Height:
*Patient's Gender:
Male
Female
*Date of Scheduled Treatment:
*Dentist/Surgeon's Name:
*Have you had a cold, cough or fever in the last two weeks?
Yes
No
*Explain:
*Have you ever been hospitalized or had a major operation?
Yes
No
*Explain:
*Have you ever had a serious head or neck injury?
Yes
No
*Explain:
*Have you or any relatives had complications with anesthesia?
Yes
No
*Explain:
*Do you have Asthma or other respiratory problems?
Yes
No
*Explain:
*Have you taken any prescription or over-the-counter medications including herbals or steroids?
Yes
No
*Explain:
*Do you use tobacco or exposed to second hand smoke?
Yes
No
*Explain:
*Have you taken any illegal substances or recreational drugs?
Yes
No
*Explain:
*Do you have an Advance Directive?
Yes
No
*Explain:
Page 2 - Medical History