Adult Anesthesia Intake Form

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If you have been referred by your provider's office, please complete this form to begin the process of anesthesia clearance. For questions, please call our office at 615-423-8390.

Email *

Patient Name *

Date of Birth *

Phone Number *

Address *

Estimated Procedure Date *

Referring Dentist/Physician *

Facility/Hospital Name *

Primary Care Physician and Phone Number *

Specialists (Cardiology, Pulmonary, Renal, Neurology, etc.) and Details *

Height and Weight *

Medical History *

Heart Disease (murmur, stent, pacemaker, etc.)

Atrial Fibrillation

High blood pressure

Stroke/TIA

Diabetes Type 1 or Type 2; please list most recent A1C below.

Lung disease (COPD, asthma, sleep apnea, etc.)

GERD or acid reflux

Kidney disease

Liver disease (hepatitis, cirrhosis, etc.)

Bleeding or clotting disorders

Seizures or epilepsy

Psychiatric disorders (anxiety, depression, schizophrenia, mood disorder, etc.)

Chronic pain

Other health conditions/concerns

Required

If you checked any of the boxes above, please list details here.

Are you taking any blood thinners? *

Yes

I don't know

For females: Are you pregnant or could you possibly be pregnant?

Yes

Maybe

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Allergies (medication or Latex) *

List all prescription and nonprescription medications with dose; please include all over-the-counter, herbal, and recreational medications. *

Previous surgical history with year: *

Problems or concerns with anesthesia: *

Family history of anesthesia problems? *

Airway Evaluation *

Difficulty opening mouth

Difficulty moving neck

History of difficult intubation

No known issues

Required

Do you smoke? *

Yes

Tobacco

Marijuana

Other

Required

If you smoke, how often?

Do you drink alcohol? How often and how much? *

Do you use recreational drugs? Please list substance and frequency. *

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