Patient Health Information Questionnaire

Please Complete and Print this form and bring it with you to your appointment

Have you had? (Patient to Complete)
1. Heart problems, congestive heart failure, heart attack,
high blood pressure, heart murmur, abnormal cardiogram,
blood clot, pacemaker defibrillator.
Yes No
2. Lung disease: asthma, emphysema, bronchitis,
abnormal chest x-ray, tuberculosis, sleep apnea.
Yes No
3. Seizures, glaucoma, nervous system disease, stroke,
muscle weakness, paralysis.
Yes No
4. Jaundice, hepatitis, cirrhosis. Yes No
5. Kidney or bladder disease, stones, severe infection. Yes No
6. Metabolic problems: diabetes, thyroid, adrenal etc. Yes No
7. Back injuries or surgery, broken bones. Yes No
8. Stomach or intestinal problems, ulcers, colitis,
hiatal hernia, reflux, gastric.
Yes No
9. Blood transfusions: Date Yes No
10. Objections to blood transfusions.
Yes No
Even if life in danger? Yes No
11. Appropiate blood transfusion refusal form signed. Yes No
12. Blood disease, abnormal bleeding tendencies. Yes No
13. Anticoagulant therapy (blood thinners). Yes No
14. Have you been tested for HIV (AIDS)? Yes No
15. Are you pregnant?
Last menstrual period date .
Maybe Yes No
16. Other medical illness. Yes No
Age Height Weight

Office use only (do not fill in shaded area)

When did you last eat or drink anything?


Do You...
1. Smoke? Yes No pkg/d Years
Quit smoking? Date
2. Use alcohol?. None Socially Moderately Heavily
3. Have a history of substance abuse? Yes No
4. Wear eyeglasses/Contacts? Yes No Contacts in out
  • 5. Dentures
  • Bridges
  • Caps
  • None

6. Loose/damaged teeth


7. List previous surgeries and dates

8. Have a problem to discuss with an anesthesiologist? Yes No
9. Did you have any abnormal anesthetic reactions? Yes No
10. Did you any relatives with abnormal anesthetic reactions? Yes No
Medications/Herbs/Vitamins:(List all medications/dose taking)

I understand this information is important to my medical care and is correct

Patient signature


Office use only (do not fill in shaded area)

Anesthesia Evaluation
(Anesthesia to complete)
Date Time NPO
RX medication(s) before surgery
History :

Anesthesia benefit/options with attendant risk and complications discussed with patient/family. Questions answered Yes No

Procedure proposed:
Dental Airway
Plan Inform consent given by
Admit to recovery
Date: Time:
  • O2 sat
  • %BP
  • P
  • R
  • Temp
Time care turned over to PACU nurse:
Post Anesthesia Evaluation
Date: Time:
  • O2 sat
  • %BP
  • P
  • R
  • Temp
Neuro/LOC: WNL
Pulm: WNL
Complication: none

Oklahoma Kidney Store Center
Anesthesia Questionnaire and evaluation

Please Complete and Print this form and bring it with you to your appointment