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Medical History
Patient Information Form
Name
Date of Birth
Age
Weight (kg)
Height (cm)
Have you had fever or inflammation in the past two weeks?
Yes
No
Do you have any allergies to medications?
Do you take any medications regularly?
Have you had any surgeries in the past? What kind?
Have you ever been under anesthesia?
Yes
No
Were there any complications after anesthesia?
Do you suffer from motion sickness?
Yes
No
Do you have shortness of breath? When?
Can you climb two flights of stairs without experiencing difficulty breathing?
Yes
No
Do you have high or low blood pressure?
High
Low
Normal
Have you ever had a stroke?
Yes
No
Do you suffer from heart diseases?
Yes
No
Do you suffer from lung diseases?
Yes
No
Do you frequently experience acid reflux?
Yes
No
Do you suffer from liver diseases?
Yes
No
Do you suffer from kidney diseases?
Yes
No
Do you suffer from endocrine diseases such as diabetes or thyroid disorders?
Yes
No
Do you have digestive system or bowel problems?
Yes
No
Do you have loose teeth or require dental treatment?
Yes
No
Do you have any foreign objects in your body, such as a heart stent, artificial joint, or artificial heart valve?
Yes
No
Do you consume alcohol?
Yes
No
Do you use drugs?
Yes
No
Are you a smoker?
Yes
No
For women: Are you pregnant or breastfeeding?
Yes
No
Submit
