Health
History
Patient
Name
Date
Patient's
Current:
Height
Weight
Medications
that you take: (Include any over the counter or herbal
medicines)
When
did you last take your medication?
Circle
Yes or No to the following questions
Have
you or any relative had problems with anesthesia?
Yes
No
If
yes, please explain
Are
you allergic to any medications, penicillin, codeine,
iodine ect.?
Yes
No
If
yes, please list
Do
you have other allergies: fruit, soy, eggs, adhesive
tape, Latex?
Yes
No
If
yes, please list
Yes
No
Do
you drink alcohol?
How
much?
Do
you use recreactional drugs?
What
do you use?
Do
you smoke?
How
much?
Have
you ever smoked?
When
did you quit?
Do
you have or have you ever had the following symptoms?
Please indicate by checking Yes or No
Central
Nervous System :
Yes
No
Yes
No
Paralysis/Weakness
Numbness
Convulsions
Unconsiousness
Migraine
Headache
Dizzy
spell/Motion sickness
Respiratory
System:
Yes
No
Yes
No
Cough,
every day
Shortness
of breath
TB/Valley
Fever
Cold/Sore
throat past 2 weeks
Asthma
Snore/Sleep
apnea
Bronchitis/emphysema
Cardiac:
Yes
No
Yes
No
Chest
pain/Heart attack
Stroke
Phleitis/clots
on leg
High
blood pressure
Fast/skipped
heart beat
Sickle
cell disease
Bleeding
tendencies
Anemia
Mitral
Valve Prolapse
Miscellaneous:
Yes
No
Yes
No
Hepatitis/jaundice
Diabetes
Cirrosis
of liver
Thyroid
problems
Blood
in urine
Hiatal
Hernia
Peptic
ulcer disease
Arthritis
Kidney/bladder
infection
If
you checked YES to any of the above, please explain:
