PREOPERATIVE ASSESSMENT

Allergies Are you allergic to any medications that you know of? Yes or No

If yes list:_______________________________________________________________ ________________________________________________________________ Social History Do you smoke? Do you drink? Yes Yes or or No No If so, how much and how often? _____________ If so, how much and how often? ______________ What drugs? How much and how drugs for often? ______________ or No

Do you use any recreation? Yes

or

No

Are you or do you think you may be pregnant? Yes

Surgical History What previous surgeries have you had? __________________________________ Did you have any problems with anesthesia? Have any of your relatives had a serious reaction to anesthesia? Do you take antibiotics prior to having dental work? Yes Yes Yes or or or No No No

Medication Check here if you are not currently taking any medication. Please list all prescription (including dose if possible) and over-the-counter medications you are taking. Include herbal supplements, vitamins and over-the-counter medications (e.g., aspirin). __________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________

Medical History Do you have high blood pressure or any heart problems? Please check all that apply. High blood pressure Chest pain (Angina) Heart murmur Heart attack Pacemaker Irregular heart beat Fatigue climbing two flights of stairs or walking two blocks Defibrillator

Have you had any problems with your lungs or breathing? Please check all that apply. Asthma Emphysema Productive cough Sleep Apnea

Have you had any problems with your blood? Please check all that apply. Anemia Prolonged bleeding Sickle cell disease Bruise easily

Do you have any problems with your nerves, muscles or joints? Please check all that apply. Seizures Physical disabilities Fainting or dizziness Psychiatric illness Strokes Muscle weakness

Have you had or do you have any problems in any of the following areas? Please check all that apply. Diabetes or 'high sugar' Reflux/GI problems Thyroid disease HIV/AIDS Kidney/Bladder Cancer Hepatitis/Jaundice Other ________