New Patients

New patients: Please complete this form.

Full name

Best number to contact the patient directly

Date of birth

Height

Weight

Gender assigned at birth

Male

Female

Please list any drug allergies

Best pharmacy for you to pick up medication (address or cross streets)

Office where surgery is to be performed

Do you have a personal or family history of problems with anesthesia?	Yes No
Do you see a cardiologist or have a history of heart issues? (i.e. irregular rhythm, coronary, artery disease, congestive heart failure, valve issues)	Yes No
Please describe heart issues
Do you see a pulmonologist or have a history of lung issues or shortness of breath on exertion? (i.e. asthma,chronic obstructive pulmonary disease/COPD)	Yes No
Please describe lung issues
Do you use marijuana?	Yes No
Are you being treated for diabetes?	Yes No
Have you been treated for bone density issues? (i.e. osteoporosis, ostepenia)	Yes No
Have you been treated for cancer?	Yes No
Is there any possibility that you may be pregnant?	Yes No