St. Jude Medical Center - Anesthesia Risk Assessment

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Anesthesia Risk Assessment

This form provides you with a free anesthesia evaluation and a personalized comprehensive printout with questions you can discuss with your anesthesiologist and surgeon before your surgery day.

Age:

Height in Feet:

Inches:

Weight in pounds:

Please list any
medication allergies
and your reaction:

Disclaimer: St. Jude Medical Center provides this form assessment as a services to our web site visitors and this is neither an endorsement or recommendation of any sponsors of this form or its final output. The resulting printout is provided as a service to allow discussion with your physician, and to allow you to have input into your Anesthesia Plan of Care. Any or all recommendations may change after a thorough history and physical exam are performed by your physician.

St. Jude Medical Center, 101 E. Valencia Mesa Drive, Fullerton, CA 92835 (714) 871-3280