Pre-Operative Form

Name:       Birth date: Date of Surgery: 

Surgeon:    Personal Physician:

Planned Surgery:

Latex Sensitivity Questionnaire:

Allergies

1.    2.     3.

4.    5.     6.

Current Medications:  Include Dosage and Frequency

1.    2.     3.

4.    5.     6.

7.    8.     9.

Previous Surgeries/Hospitalizations:

Anesthesia History:

Select One Never had anesthesia Yes No Have you ever had problems with Anesthesia?

Select One Yes No History of high temperatures with Anesthesia?

Select One Yes No Had trouble having a breathing tube in your throat?

Gastrointestinal:   Do you have?

Select One Yes No Ulcers or stomach problems (nausea or vomiting)   

Select One Yes No Liver problems or jaundice

Select One Yes No Hiatal Hernia / Reflux             

Cardiovascular:    Do you have?

Select One Yes No High Blood Pressure

Select One Yes No Blood Clots / Phlebitis

Select One Yes No Racing or skipped beats

Select One Yes No Chest pain or tightness

Select One Yes No Heart Attack

Select One Yes No Bypass Surgery

Select One Yes No High Cholesterol

Select One Yes No Shortness of breath 

Select One Yes No Swollen feet or ankles             

Select One Yes No Stroke

Select One Yes No Fainting / Dizziness

Select One Yes No Pacemaker / AICD  

Do you do any of the following:        

Select One Yes No Do you use Tobacco - If Yes, Smoke or Chew:  

                    How many Packs/Cans per day:

Select One Yes No Alcohol       

Select One Yes No Street Drugs

Respiratory System:  Do you have?

Select One Yes No Asthma

Select One Yes No Sinus Problems

Select One Yes No Emphysema

Select One Yes No Chronic or Frequent Cough     

Select One Yes No Abnormal Chest X-Ray           

Select One Yes No Sleep Apnea

Select One Yes No CPAP Machine Use.  If Yes, how many liters?

Select One Yes No Home 02 Use.  If Yes, how many liters?

Renal System:     Do you have?

Select One Yes No Renal / Kidney problems

Gynecological:   Do you have?

Select One N/A Yes No Are you Postmenopausal?

Select One NA Yes No Do you have regular periods?

Select One NA Yes No Are you Pregnant / Breastfeeding?

Select One NA Yes No Last Period

Select One N/A Yes No Have you had Tubal Ligation / Hysterectomy?

Miscellaneous:    Do you have?

Select One Yes No Do you have diabetes?

Select One Yes No Do you have any implants?  If so what is the location:

Select One Yes No Thyroid or goiter problems

Select One Yes No Arthritis

Select One Yes No Bleeding or blood problems

Select One Yes No Glaucoma

Select One Yes No Seizures / Convulsions

Select One Yes No Prostate Problems

Select One Yes No Immune System Disorders?

Select One Yes No HIV

Select One Yes No Hepatitis

Select One Yes No Do you take blood thinners?

Select One Yes No Use Over The Counter herbal medications?     Date last taken:

Select One Yes No Have you ever been diagnosed with and treated for cancer?   

                    Please describe Diagnosis and Treatment:

Height:       

Weight:      

Daytime phone number for contact: 

Cell phone number for contact: