Drs. Rubens & Steen

18807 Beardslee Blvd., Suite 102
Bothell, WA 98011

Phone: (425) 489-8274
FAX: (425) 487-9506

Name Title Date
Birth Date   Age   Height   Weight
Your medical history is very important to us. During the course of your routine care, Dr. Steen/Peysakhov/Rubens may prescribe antibiotics, pain medication, anti-inflammatory agents, antihistamines, as well as administer local anesthetics, sedatives, narcotics, steroids or several other types or combinations of drugs that may affect your health and wellbeing. No medications are administered without your express permission. It is very important to answer all questions truthfully and to the best of your knowledge to help plan your individual treatment and avoid any unnecessary personal health risks.
How would you estimate your general health? Have you or a family member ever experienced a bad reaction to general anesthesia?
Do you have any medical problems that you think Dr. Steen/Peysakhov/Rubens should be aware of?
 Who is your personal physician? Phone
 Are you presently under care for a medical problem?   Yes    No
Date of last physical exam:   Reason for physical exam:
Please list your medications:
Have you had any serious illnesses, operations, or hospitalizations in the last two years?
Yes    No      Please describe:
Dr. Steen/Peysakhov/Rubens will discuss anesthesia options with you during your consultation. Do you prefer to be:
Awake For Your Surgery      Asleep For Your Surgery
Allergies or bad reactions to medications:
Medication: Reaction:
Medication: Reaction:
Have you or a family member ever experienced a bad reaction to general anesthesia?   Yes    No
Please describe:

The following questions are critical if you are contemplating a general anesthetic or are being evaluation for a pathologic lesion:

Have ever smoked? Yes No      Presently Smoke? Yes No      Packs per day   Years
Do you drink alcohol? Yes No     Have you ever been treated for drug or alcohol abuse? Yes No
Have you ever abused: Cocaine Heroine   LSD Marijuana   Meth  

Have you ever had: Joint Replacement  Heart Surgery   LSD Pacemaker   Artificial Valve  
Have you ever been at risk of or tested for: HIV (AIDS)  Hepatitis   TB CMV  
Have you ever had a problem with bleeding after oral surgery / tooth extraction? Yes No
Have you ever had or been treated for any of the following diseases (please check all that apply):
Depression Ulcers/Colitis Chest Pain
Bipolar Disorder Crohn’s Disease Heart Attack
Neurologic Disorder Hemophilia DVT/Embolism
Multiple Sclerosis Thrombocytopenia Cancer
Anxiety High Blood Pressure Radiation Therapy
Epilepsy Low Blood Pressure Osteoporosis
Stroke / TIA Dizziness/Fainting Osteopenia
Migraine Headaches Splenectomy Arthritis Scoliosis
Mental Disability Neck/Back Surgery TM Joint Disorders
Malignant Hyperthermia Sleep Apnea Ibuprofen Allergy
Myasthenia Gravis CPAP Allergy To Eggs
Diabetes Bronchitis Hay Fever
Thyroid Disease Emphysema Asthma
Pancreatitis Shortness Of Breath Fibromyalgia
Kidney Disease Glaucoma Chronic Pain
Kidney Dialysis Facial Trauma Venereal Disease
Liver Disease Sinus Disease Obesity (Surgery)
Jaundice Anemia Heart Murmur    
Blood Transfusion Mitral Valve Prolapse    
Stomach/Gastric Surgery Heart Failure    
Women: Some medications used in Oral and Maxillofacial Surgery will cross the placental barrier and breast milk barrier. Some antibiotics may reduce the effectiveness of birth control pills. Some medications may affect an unborn fetus.
Are you pregnant ? Yes No  Don't Know         Are you breast feeding? Yes No
Do you take Birth Control Pills? Yes No

Would you like to speak privately with Dr. Steen/Peysakhov/Rubens about any health issues? Yes No

I have read and understand the questions on the health history. I have also had the opportunity to discuss my health history as it applies to my treatment and have answered the questions to the best of my ability.
 Signature of Patient or Legal Guardian Date
Dr. Steen/Peysakhov/Rubens Signature                                                                                           Date                               Update
This form  will be retained in the patient’s record close