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Pre-Surgery Health Clearance Form - Free Healthcare Template | ZenBuild | ZenBuild

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Pre-Surgery Health Clearance Form

Collect health history and risk factors from patients prior to elective or scheduled surgical procedures.

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Pre-Surgery Health Clearance Form

Collect health history and risk factors from patients prior to elective or scheduled surgical procedures.

Patient Full Name*

Scheduled Procedure*

Do you have any of the following medical conditions? (select all that apply)*

Heart disease or history of heart attackHypertensionDiabetesKidney or liver diseaseBleeding disorderNone of the above

Have you or any family member had a reaction to anesthesia?*

YesNoNot sure

Are you currently taking blood thinners or anticoagulants?*

YesNo

Do you smoke or use tobacco products?*

YesNoFormer smoker

List all current medications, vitamins, and supplements*

Additional medical history or concerns relevant to your surgery

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views0

healthcarepre-surgeryclearancesurgicalanesthesia