You can insert any text here
There are sample questions below - but you can choose your own (unlimited number) - including drop down lists, multiple choice formats etc.
You can also choose which questions are mandatory and which are not.

Surgeon name:
Date of procedure:
Patient name:
Contact number (and name if not the patient):
Surgical procedure:
Email:
List any prior surgeries
Describe any problems with prior anaesthetics
Relevant medical history (eg. asthma, diabetes, hypertension, cardiovascular disease, stroke/TIA, other)
Allergies & reactions
Regular medications
Describe any loose teeth, caps, crowns or dentures
Patient's weight (kg)
Patient's height (cm)

Welcome to your Dr Your Name