Children’s Healthcare Of Atlanta


Children's at Scottish Rite Surgical Services

Preanesthesia History Form
If you have any questions, contact the presurgery phone nurse: 404-785-4664
  * Required Fields
     
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  Child's Legal Last Name:  
  Child's Legal First Name:  
  Nickname:
  Surgeon:
  Pediatrician Name:
  Pediatrician Phone:
  Today's Date:
  Date of Birth: //   
  Age:
  Sex:
Height must be written in feet and inches.
  Height: (feet)   (inches)  
  Weight: (pounds)  
Click Calculate
  BMI (Body Mass Index):  
  Operation:  
  Date of Surgery:   (mm/dd/yyyy)  
 

 

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