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    • "Thanks for giving John such good care. We appreciate your service and will ask if you will do it again in a year"
    - Jeanne H.
    *special needs patient.
    Listed below are two methods for submitting the pre-appointment information. You can either: 1) print the pdf version of the form, fill it out by hand, and mail or fax it to us, or, 2) fill out the online form and click "submit" to send it to us by e-mail.

    [ Medical History Form - Adult ]

    Use this form if you wish to print out a PDF of the form and fax it to our offices.

    (Adobe Acrobat Reader required)
    click here to download)

    OR

    Use this form if you would like to fill out the form Online and have it sent via email to our offices. You will need to print out the additional PDF file and bring it with you to your appointment.

    [ Medical History Form - Pediatric ]

    Use this form if you wish to print out a PDF of the form and fax it to our offices.

    (Adobe Acrobat Reader required)
    click here to download)

    OR

    Use this form if you would like to fill out the form Online and have it sent via email to our offices. You will need to print out the additional PDF file and bring it with you to your appointment.

    Medical History Form - Adult

    Medical History Form - Adult [ Online Form ]

    Filling out the online form is a simple two step process.
    Step 1 - fill out the web form below.
    Step 2 - click on the link for "Patient Instruction Sheet - Adult" and print the document.


    Step 1
    Patient Name:   Wt:

    This form is to be completed and returned to our office at least one week prior to the day of your surgery. All information is essential to insure your comfort and safety for a procedure requiring the administration of intravenous medications. All information will be held in the strictest of confidence, and will become a permanent part of the surgeon's office records. None of this information will be released without written permission from you. If you need additional space for your answers, please use the back of this form. Please circle the appropriate letter below.
    1)  Please list all past surgeries and approximate year they were performed.
    2)  Have you or anyone in your family ever had a problem with an anesthetic? Yes  No
    If so, explain:
    3)  Any allergies, sensitivities, or adverse reactions to any medications? Yes  No
    If so, explain:
    4)  List all medications which you are currently taking.
    5)  Do you have a history of heart problems (including angina, heart attack, congestive heart failure, valve disease, murmur, pacemaker, or arrhythmia)? Yes  No
    If so, explain:
    6)  Do you have high blood pressure? Yes  No
    If so, explain:
    7)  Have you ever had a stroke? Yes  No
    If so, state when, and any residual effects.
    8)  Have you ever been diagnosed as having a lung disease (incl. asthma, emphysema, TB, pneumonia, etc.)? Yes  No
    If so, explain.
    9)  Do you smoke? Yes  No
    If so, how many packs a day, and for how many years?
    10)  Have you had a recent cold or cough? Yes  No
    11)  Do you have a history of kidney disease? Yes  No
    If so, explain.
    12)  Do you have a history of liver disease (hepatitis, jaundice, etc.)? Yes  No
    13)  To your knowledge, have you ever been exposed to the HIV virus? Yes  No
    14)  Do you have a history of diabetes or hypoglycemia (low blood sugar)? Yes  No
    If so, explain:
    15)  Do you have a history of thyroid problems? Yes  No
    If so, explain:
    16)  Do you drink alcohol or use drugs socially or recreationally? Yes  No
    If so, list type(s) and amount.
    17)  Are there any other medical problems which you feel we should know about? Yes  No
    If so, explain:
    The above questions have been answered fully and to the best of my knowledge.
    Patient or responsible party:

    Step 2

    Download the additional "Patient Instruction Sheet - Adult" form. Make sure to print and sign. Please make sure that you bring this form with you to your appointment.
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