Name: 
Age: 
Birthdate: 
Present and/or Recent Medications (including OTC):

Allergies or Adverse Effects: No   Yes (list medication and reaction):

Previous Surgeries: No Yes  (list)

Anesthesia Problems: No Yes   (list)


Cancer, Including Leukemia      Glaucoma
 No   Yes                        No Yes
Tuberculosis                             Sickle Ceil Anemia
 No Yes                         No Yes
Heart Trouble                           Other Anemia
 No Yes                         No  Yes
High Blood Pressure                 Mental Illness
 No Yes                         No Yes
Stroke                                      Suicide Attempt
 No Yes                         No Yes
Epilepsy                                    Other Serious Disease
 No Yes                          No Yes   Please explain:
Bleeding Disorder                      Diabetic
 No Yes                          No Yes   How Long:
Asthma                                      Alcohol Usage
 No Yes                          No Yes   Amount:
Allergies                                    Cigarettes
 No Yes                          No Yes   Amount:
Liver Disease                             Caffeine
 No Yes                           No Yes   Amount:
Migraine Headaches                   Drug Usage
 No Yes                           No Yes   Amount:
Alcoholism                                 Stomach or Duodenal ulcer 
 No Yes                           No Yes
Emphysema                                Kidney Disease
 No  Yes                           No Yes
                    Age Living          Age Died             Cause of Death
Mother             
Father              
Siblings            
Family History/Cancer: No  Yes
Family History/Heart: No Yes
Questions or Comments: