Patient Medical History Form Page 3

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Past Surgical History
What surgical procedures have you had?
(List all procedures, and if possible include the dates.)
1.
2.
3.
4.
5.
6.
Prescribed Medications
What medications are your currently taking?
(List all pills, patches, and any other forms of prescribed medications.)
1.
Dose:
2.
Dose:
3.
Dose:
4.
Dose:
5.
Dose:
6.
Dose:
Allergies
What medications, food, or misc. substances are you allergic to?
(Please describe type of reaction.)
1.
Reaction:
2.
Reaction:
3.
Reaction:
General Anesthesia
Have you ever had procedures under general anesthesia?
q Yes
q No
If ü YES, did you have any adverse reaction?
Specify _______________________________
3

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