Medical Pre-Procedure Questionnaire Form
Please complete this questionnaire before your medical procedure so the care team can review your health history, medications, allergies, and preparation details.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Procedure Details
Procedure Name / Type
*
Scheduled Procedure Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Referring Doctor or Clinic Name
Location / Facility
Medical History
Medical conditions or diagnoses
Diabetes
High blood pressure
Heart disease
Asthma
Sleep apnea
Bleeding disorder
Seizures
Kidney disease
Liver disease
Thyroid disorder
Cancer
Other
Prior surgeries or procedures
History of anesthesia or sedation reaction
*
No
Yes
Unsure
Family history relevant to anesthesia or procedure
Current symptoms or recent illness
*
Medications and Allergies
Current medications, including over-the-counter medicines and supplements
Do you have any medication allergies?
*
No
Yes
Do you have any food allergies?
*
No
Yes
Do you have a latex allergy?
*
No
Yes
If you have any allergies, describe the reaction and severity
Pre-Procedure Screening
Pregnancy status
Not applicable
Not pregnant
Pregnant
Unsure
Prefer not to say
Smoking or vaping status
Never
Former
Current
Prefer not to say
Alcohol or substance use relevant to procedure prep
Alcohol
Cannabis
Tobacco
Other substance
Have you followed fasting or NPO instructions?
*
Yes
No
Not instructed
Unsure
Other preparation notes or special accommodations
Submit
Should be Empty: