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First Name
Last Name
Patient Email
*
We will only use this to contact you for scheduling and care related information.
Date of Birth
*
Month
Day
Year
Upload Identification
ID (front)
*
Max. file size: 300 MB.
ID (back)
*
Max. file size: 300 MB.
Upload Insurance Card
Insurance Card (front)
*
Max. file size: 300 MB.
Insurance Card (back)
*
Max. file size: 300 MB.
Anesthesia & Home Care
Medical History
*
Manually Enter
Upload Files
Medical History (manual)
*
Medical History (upload)
*
Drop files here or
Select files
Max. file size: 300 MB.
Social History
*
Institutionalized
Day Center Participant
Nursing Home
Wheelchair User
Assistive Device User
None
Relevant Dental History
*
Sedation
OR
Extra Time
None
Emergency Contact Information
Contact Name
*
First
Last
Emergency Contact Phone
*
Relationship to Patient
*
Medical & Dental History
What type of procedure are you scheduled for?
*
Do you have any pre-existing medical conditions?
*
Yes, I have pre-existing medical conditions
No pre-existing medical conditions
(e.g., heart disease, diabetes, lung conditions)
Please specify your pre-existing medical conditions.
*
Have you undergone anesthesia before?
*
Yes
No
Please describe your experience and any complications.
*
Are you allergic to any medications or anesthesia agents?
*
Yes, I am allergic to medications or anesthesia agents
No, I am not allergic
Which medications or anesthesia agents are you allergic to?
*
Are you currently taking any medications?
*
Yes, I am currently taking medications
No, I am not taking any medications
Please list medications:
*
Do you consume alcohol or recreational drugs?
*
Yes, I consume alcohol or drugs
No, I do not consume alcohol or drugs
Please specify the frequents and/or types of drugs:
*
Are you a smoker?
*
Yes, I'm a smoker
No, I'm not a smoker
How many cigarettes do you smoke per day?
*
Do you have a caregiver or support person at home who can assist you after the procedure?
*
Yes, I have a caregiver or support at home
No, I don't have any support
Please describe your home situation:
*
Will you have reliable transportation to and from the procedure location?
*
Yes, I have transportation
No, I don't have transportation
How would you rate your anxiety level regarding the upcoming procedure?
*
1 - No anxiety at all
2
3
4
5
6
7
8
9
10 - Extreme Anxiety
Scale of 1-10, with 10 being the highest
What level of comfort do you prefer during the procedure?
*
Minimal Discomfort
Mild Sedation
General Anesthesia
Other
Is there anything else you would like us to know regarding your anesthesia or home care needs?
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