Summit Anesthesia

MEDICAL HISTORY QUESTIONNAIRE

Please take time to carefully fill out this questionnaire.

*Patient's First Name

*Patient's Last Name

*Patient's Address

*Patient's City

*Patient's State

*Patient's Zip

*Patient's Primary Phone

Patient's Alternative Phone

*Patient's Date of Birth

*Patient's Age

*Patient's Weight

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

*Have you ever been hospitalized or had a major operation?

Yes

*Have you ever had a serious head or neck injury?

Yes

*Have you or any relatives had complications with anesthesia?

Yes

*Do you have Asthma or other respiratory problems?

Yes

*Have you taken any prescription or over-the-counter medications including herbals or steroids?

Yes

*Do you use tobacco or exposed to second hand smoke?

Yes

*Have you taken any illegal substances or recreational drugs?

Yes

*Do you have an Advance Directive?

Yes