Dates
Pre-Registration Date Date Of Surgery
 
Personal Information
First Name Race
Middle Name Sex
Last Name Marital Status
Maiden Name Home Phone
Date Of Birth
Cell Phone
SS # Best Number To Reach You At
Email Address

Address Line 1 State
Address Line 2 Zip
City

Employer Name Employer Phone
 
Spouse / Parent
First Name Last Name
SS # Date Of Birth

Employer Name Employer Phone
 
Visit Information
Is this visit due to an accident?
Explain
Do you have an Advanced Directive or Living Will?
Patient Permission to Leave Message on Machine or with Family Member?
 
Insurance Information
Insurance Company
Contract Number
Group Number
Insurance Address (If Known)
Insurance Phone # (If Known)
 
Medical Information
Height Weight Pharmacy
List All MEDICATION Allergies and Reactions
List All FOOD Allergies and Reactions
Are you allergic to BANDAIDES, TAPE, or LATEX?
Do you take BLOOD THINNERS or DIET MEDICATION?
List all medications you are taking including:
PRESCRIPTIONS, OVER-THE-COUNTER, VITAMINS, INHALERS, or NEBULIZERS
Name of Medicine Dosage Frequency Last Taken
Add / Remove A Row: Add A Row Remove A Row
Family Dr. Heart Dr. Lung Dr.
Have you or any BLOOD RELATIVES ever had a problem or severe reaction to ANESTHESIA?
If so who and reaction:
Have you ever been tested and told that you have SLEEP APNEA?
Do you use a CPAP?
Is your sleep apnea mild, moderate, or severe
 
Medical History/Review of Symptoms
Cardiovascular
None
Respiratory
None
GI/Endocrine
None
Neuromuscular
None
High Blood Pressure COPD Acid Reflux Headaches
Heart Attack/Coronary Emphysema Peptic Ulcers Stroke
Heart Stent Asthma Irritable Bowel Syndrome Seizures
Angina/Chest Pain Oxygen Use Hepatitis Parkinson
Poor Circulation Sleep Apnea Diabetes Depression
Irregular Heart Beat CPAP use Hypoglycemia Anxiety
Pacemaker/AICD Resp. Infection Thyroid Disease Fibromyalgia
Valve Prolapse Obesity Alzheimer's
Coronary Bypass Arthritis/Gout
Poor Exercise Tolerance Mental Illness
Open Heart Surgery
Heart Valve Disease
Congestive Heart Disease
Other Cardiovascular Problems:
Other Respiratory Problems:
Other GI/Endocrine Problems:
Other Neuromuscular Problems:
If you chose yes for hepatitis, what type?
GU/GYN
None
HemeOnc
None
Anesthesia/Airway
None
Pediatric
None
Kidney Disease Anemia Family History of Anesthetic Problems Recent URI Illness
Incontinence Cancer Previous Anesthetic Complications Prematurity
Prostate Problems Leukemia Maligant Hyperthermia Congenital Anomaly
Interstitial Cystitis Bleeding Disorder Malignant Hyperthermia Apnea
Urinary Tract Infection Sickle Cell Disease/Trait Severe Nausea
Pregnant HIV Dentures/Partials
Last Menstrual Cycle
Other GU/GYN Problems:
Other Heme/Onc Problems:
Other Anesthesia/Airway Problems:
Other Pediatric Problems:
Comments on Positives or Symptoms/Conditions Not Listed:
 
Miscellaneous
Alcohol Use None Weekly Daily Occasionally
Drug Use Type Last Used
Tobacco Use Packs Per Day
How Long Have You Smoked?
How Long Since You Have Quit?
Are you on a special diet? Yes No
Any unexpected weight loss? Yes No
Any problems swallowing or chewing? Yes No
Any religious/spiritual beliefts that could affect care? Yes No
If yes, please specify
 
Surgical History
Aneurysm C-Section Laparoscopy Sinus
Appendix Ear Tubes Hernia Repair Tonsils
Rectal Cataracts Hemorrhoid Thyroid
Bladder Tubal Ligation Hip Replacement Vasectomy
Kidney Carpal Tunnel Mastectomy Right Mastectomy Left
Kidney Stone Gallbladder Pacemaker Stomach
Back Colon Lung Open Heart
Neck D And C Prostate Hiatal Hernia Repair
Breast Hysterectomy Shoulder
Knee Replacement Left Knee Replacement Right
Knee Scope Left Knee Scope Right
Other surgical histories: