Patient Health History Form

Genesis Anesthesia Services – Pre-Op Health Questionnaire

Please complete all sections. This information is required for safe anesthesia care.

Patient Information

Full Name *

Date of Birth *

Age

Height

Weight

Phone *

Email *

Emergency Contact Name

Emergency Contact Phone

Procedure Information

Procedure

Procedure Date

Dentist/Provider/Facility

Allergies

No known allergies

Allergies (list + reaction)

Latex allergy

Medications

List all medications (include inhalers, vitamins, herbals)

Anesthesia History

Have you had anesthesia/sedation before?

YesNo

Patient Confirmation

I confirm the above information is true and complete.

By checking this box, I acknowledge that I have provided accurate medical information to the best of my knowledge.

Date

Communication Preferences

I agree to receive SMS/text messages from Genesis Anesthesia Services, including appointment reminders and service updates. Message frequency varies. Msg & data rates may apply. Reply STOP to opt out. Reply HELP for help.I agree to receive email communications from Genesis Anesthesia Services, including service announcements and promotional offers. You may unsubscribe at any time.

Patient Health History Form

Patient Information

Procedure Information

Medical History

Heart / Blood Pressure

Lung / Breathing

Other Conditions

Allergies

Medications

Anesthesia History

Social History

Recent Symptoms

Patient Confirmation