Name: | DOB: | Preferred daytime phone #: | |
Planned surgery: | Today's date: | ||
Surgeon: | |||
Primary care physician: | PCP phone #: | ||
Please list all previous surgeries (and approximate dates) | |||
Please list any allergies to medications, latex, food, or other (and your reactions to them) | |||
List all medications (include over-the-counter drugs, inhalers, herbals, supplements, and aspirin) | |||
Drug name | Dose and how often? | Drug name | Dose and how often? |
1. | 7. | ||
2. | 8. | ||
3. | 9. | ||
4. | 10. | ||
5. | 11. | ||
6. | 12. | ||
Weight: (lbs or kg) ____ Height: (inches or cm) ____ (Circle the measurement units you use) | |||
Please check any of the following that apply to your health: | |||
Heart attack at any time | Congenital heart disease | ||
Heart attack within past 60 days | Hypertension | ||
Chest pain or pressure with activity | Murmur | ||
Angina | Valve disorder | ||
Heart failure | LVAD | ||
Heart surgery | Heart device | ||
Heart stent in the last 6 months | Pacemaker | ||
Unable to climb 2 flights of stairs or walking 2 blocks because of chest pain or trouble breathing | Defibrillator | ||
Heart stent at any time | Fainted in the last year | ||
Atrial fibrillation | Pain in legs while walking | ||
Arrhythmia | None of these | ||
Oxygen at home | COPD | ||
Pulmonary hypertension | Pneumonia in last 2 months | ||
Trouble breathing at rest or with minimal exertions | Any problems with your lungs | ||
Asthma | Severe cough | ||
None of these | |||
Face, arm, or leg weakness | Myasthenia gravis | ||
Stroke/TIA within past 60 days | Muscular dystrophy | ||
Stroke or TIA at any time | Spinal cord injury | ||
Paralysis | Brain tumor | ||
Difficulty speaking | Brain aneurysm or AVM | ||
Dementia | Epilepsy, blackouts, or seizures | ||
Parkinson disease | None of these | ||
Hospitalized in last 30 days | Hypothyroidism | ||
Anemia | Adrenal disorder | ||
Sickle cell disease | Pituitary disorder | ||
Blood transfusion in last 3 months | Dialysis | ||
Blood clots/pulmonary embolus | Lupus | ||
Diabetes | Rheumatoid arthritis | ||
Cancer: What type? ________ | Scleroderma | ||
Chemo or radiation last 3 months | Sjögren's disease | ||
Kidney disease other than stones | Jehovah's Witness | ||
Liver disease | Use illegal drugs (excluding marijuana) | ||
Cirrhosis | Kidney failure | ||
Hepatitis B/C | Taking antibiotics for any reason | ||
Jaundice | HIV | ||
Hyperthyroidism | None of these | ||
Blood thinners or anticoagulants other than aspirin | Von Willebrands | ||
Bleeding with surgery or tooth extractions | Known bleeding disorder | ||
Hemophilia | Severe nose bleeds | ||
None of these | |||
Malignant hyperthermia (in blood relatives or self) with anesthesia | Dentures | ||
Severe nausea or vomiting from anesthesia | Problems opening your mouth | ||
Difficult airway with anesthesia | Loose teeth | ||
None of these | |||
Unintentional weight loss >10 lbs | Difficulty doing your own shopping | ||
Difficulty getting out of bed/chair by yourself | Feel that everything you did was an effort: ____ days in the last week | ||
Difficulty making your own meals | Need assistance with eating or bathing or dressing | ||
Your physical abilities limit your daily activities | Fallen in the last 6 months ( ____ times) | ||
None of these | |||
Very loud snoring | High blood pressure/hypertension | ||
Tired/fall asleep frequently during the day | Sleep apnea; NO CPAP | ||
Observed to stop breathing during sleep | Sleep apnea; use CPAP | ||
None of these | |||
Cannot speak and/or understand English | Deaf | ||
Cannot lie flat for 45 minutes | Blind | ||
Currently pregnant. Last menstrual period began: ________ | |||
Smoker (current or past) ____ packs/day for ____ years. Quit date: ________ | |||
Drink alcohol. How much each day? ____ beers ____ glasses of wine ____ shots of hard alcohol | |||
None of these | |||
Please list any medical illness or medications not noted already: |
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