Pre-Surgery Health Clearance Form

Pre-Surgery Health Clearance Form — Form Fields

This healthcare template includes 8 fields. Collect health history and risk factors from patients prior to elective or scheduled surgical procedures. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Scheduled Procedure (text, required)
• Do you have any of the following medical conditions? (select all that apply) (checkboxes, required) — options: Heart disease or history of heart attack, Hypertension, Diabetes, Kidney or liver disease, Bleeding disorder, None of the above
• Have you or any family member had a reaction to anesthesia? (multiple choice, required) — options: Yes, No, Not sure
• Are you currently taking blood thinners or anticoagulants? (multiple choice, required) — options: Yes, No
• Do you smoke or use tobacco products? (multiple choice, required) — options: Yes, No, Former smoker
• List all current medications, vitamins, and supplements (long text, required)
• Additional medical history or concerns relevant to your surgery (long text, optional)