Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Surgical History Form
Full Name *
Previous Surgeries (List)
Anesthesia History & Reactions
Surgical Complications
Implanted Devices/Hardware
Blood Transfusion History
Current Blood Thinners
Recovery Pattern
Date of Birth
____ / ____ / ________
Consent for Records Release
Date
Surgical History Form template from formisoft.com. formisoft.com/intake-templates/surgical-history