Microsoft word - pre-anesthesiaform.doc

Sarasota Physicians
Please print and fi
ll out this form carefully and completely. Take it to
Surgical Center
the Sarasota Ph
ysicians Surgical Center on the day of surgery.
Procedure: ______________________________________________
Height: _____________ Weight: ______________
Are you allergic to latex? ( Please circle and notify the nurse on admission ) Yes No
List Other Allergies:
List ALL Previous Surgeries:
_______________________________________________ _____________________________________________________
__________________________________________ _ _______________________________________________ __________________________________________ _ _______________________________________________
__________________________________________ _ _______________________________________________
Do you take any blood thinners? Coumadin
List Below ALL your other medications including ov
er-the-counter, vitamins, & herbal supplements.
Name of Medication
How taken
How often
Reason for taking
Last taken?
Leave this
this medication
column blank
Check this box if you do not take any medications


YES NO Substance Use YES NO Anesthesia Problems
YES NO Cardiovascular Disease YES NO Pulmonary Disease
Smoking History:
NO Other:
YES _____ Packs / Per day
Valve Disease/Heart Murmur Other: _____________________ _____ Years YES NO Teeth
QUIT WHEN? __________
Shortness of Breath When YES NO Endocrine Disease
YES NO Neurological Disease
Seizures/Epilepsy YES NO Infectious Diseases
Other: ___________________ YES NO GI Disease
Reviewed by Doctor _________ Reviewed by CRNA _________
YES NO Blood Disease
Reviewed by Doctor _________ Reviewed by CRNA _________
YES NO Kidney Disease
YES NO Pediatrics
Revised 6/8/09 SPSC Pre-Anesthetic Evaluation Form


Information for patients

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