Pediatric Pre-Anesthesia Intake Form
Please complete this Pediatric Pre-Anesthesia Intake Form to provide essential information prior to your child's procedure.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Child's Weight (kg)
*
Does your child have any allergies?
*
No
Yes (please specify)
List all current medications your child is taking
*
Has your child had anesthesia before?
*
No
Yes (no problems)
Yes (with complications)
Does your child have any chronic medical conditions?
*
No
Yes (please specify)
When did your child last eat or drink?
*
Parent or Guardian Name and Contact Number
*
Scheduled Procedure Name or Reason for Visit
*
Submit
Should be Empty: