Dr. Edward G. Lundblad ---579 South Laredo Circle, Aurora, Co 80017

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Previous Surgeries:

Today's Date:__________
Name:______________________________	Work Phone: (___)__________
Phone: (___)__________	Date of Birth:__________
Address:______________________________	Height:__________
_____________________________________	Weight:__________
Emergency Contact:______________________________	Relationship:______________________________
Phone: (___)__________
Please List All Current Medications:	Drug Allergies:
1.______________________________	1.______________________________
2.______________________________	2.______________________________
3.______________________________	3.______________________________
Surgery:
1.______________________________	Date:__________
2.______________________________	Date:__________
3.______________________________	Date:__________
4.______________________________	Date:__________

Have you had any of the following:

Yes / No	Yes / No	Yes / No
Anesthesia Prob:_________	Bleeding Disorder:__________	Hepatitis:______________
Breathing Prob:_________	Heart Problems:___________	Hypertension:___________
Blood Clots:____________	Diabetes:_________________	Thyroid Disease:________
Lung Problems:__________	Liver Disease:____________	Ulcers:_________________

Additional Medical History:
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Do you have any relatives who have had any problems with Anesthesia? ____