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) I confirm all my answers above are complete and accurate. Time is Up!