ANESTHESIA HEALTH HISTORY
ALLERGY OR SENSITIVITY TO:
[YES] [NO]
[ ] [ ] BENZODIAZEPINES
[ ] [ ] BARBITURATES
[ ] [ ] ANTIHISTAMINES
[ ] [ ] NARCOTICS
[ ] [ ] VALIUM
[ ] [ ] MIDAZOLAM
[ ] [ ] DEMEROL
[ ] [ ] PENTOBARBITAL
[ ] [ ] STADOL
[ ] [ ] SCOPOLAMINE
[ ] [ ] PROMETHAZINE
OTHER____________________________________
HAVE YOU HAD OR HAVE:
[YES] [NO]
[ ] [ ] GLAUCOMA-DI,SCO,PRO
[ ] [ ] PHLEBITIS-DI
[ ] [ ] ACUTE PULMONARY INSUFFIENCY-MID
[ ] [ ] RESPIRATORY DEPRESSION-DI,PEN,MID,MEP,STA
[ ] [ ] ADHESIONS BETWEEN IRIS & LENS-SCO
[ ] [ ] ASTHMA-SCO,MEP,PEN,STA
[ ] [ ] PROSTATIC DISEASE -SCO,PRO
[ ] [ ] MYASTHENIA GRAVIS-SCO
[ ] [ ] CONTACT LENSES-SCO
[ ] [ ] MAO INHIBITORS [ANTIDEPRESSANTS]-MEP
[ ] [ ] COPD [DIFFICULT BREATHING] -MEP,STA
[ ] [ ] PORPHYRIA-PEN
[ ] [ ] LIVER DISEASE -PEN,MEP
[ ] [ ] ALCHOLISM-PEN,MEP
[ ] [ ]STENOSING PEPTIC ULCER -PRO
[ ] [ ] BLADDER NECK OBSTRUCTION -PRO
[ ] [ ] NARCOTIC DEPENDENCE -MEP,STA

CONSENT TO SURGERY & ANESTHESIA
I ACKNOWLEDGE THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO DISCUSS THIS PROCEDURE
WITH THE ATTENDING SURGEONS [S]. I ACKNOWLEDGE THAT I HAVE BEEN MADE AWARE THAT THERE ARE RISKS, COMPLICATIONS AND CONSEQUENCES KNOWN AND OF ANESTHESIA RECOMMENDED. I ACKNOWLEDGE NO GUARANTEE OR PROMISE ORAL OR WRITTEN HAS BEEN GIVEN BY ANYONE, EITHER AS TO THE RESULTS THAT MAY BE OBTAINED OR TO THE RISKS, CONSEQUENCES AND COMPLICATIONS THAT MAY FOLLOW SURGERY, MEDICAL TREATMENT AND OR ADMINISTRATION OF ANESTHETIC.
I HAVE READ [OR HAVE HAD READ TO ME] THE ABOVE ‘CONSENT TO SURGERY, ANESTHETICS AND MEDICAL TREATMENT’ AND I FULLY UNDERSTAND IT.
SIGNATURE: ___________________________________________________