Tuesday-May 13, 2008 
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Pre-Surgery Form Patient: Please fill out this form and print for the hospital. Your information is not visible, submitted or stored in any way on the YourSurgery.Com site.
 Patient Personal Information
Patient Name
Date of Birth
Proposed Operation
Height
Weight

 Do you have or have you ever had
Heart Disease Yes    No
Chest Pain Yes    No
Irregular Heart Beat / Pacemaker Yes    No
Mitral Valve Prolapse / Heart Murmur Yes    No
High Blood Pressure Yes    No
Recent Cough or Cold Yes    No
Lung Disease Yes    No
Asthma; Wheezing Yes    No
Bronchitis / Emphysema Yes    No
Use Tobacco? Yes    No
Packs Per Day
A History Of Sleep Apnea? Yes    No
Kidney Disease Yes    No
Liver Disease / Jaundice/ Hepatitis Yes    No
Hiatal Hernia / Heart Burn/ Reflux Yes    No
Bleeding, Blood Disorder, Anemia Yes    No
Sickle Cell Disease Yes    No
AIDS/ HIV or at risk Yes    No
Diabetes Yes    No
Thyroid Disease Yes    No
Seizures Yes    No
Stroke Yes    No
Other ILLNESS Yes    No

 Have you had
Blood Thinner in past month Yes    No
Cortisone/ Steroids within past year Yes    No
A bad reaction to ANESTHESIA Yes    No
Relative with Reactions to ANESTHESIA /
Malignant Hyperthermia		 Yes    No
Pediatric: Patient under 12 years Yes    No
Abnormalities at Birth? Yes    No
Premature? Yes    No
How Early?
Birth Weight?

 Do you
Drink Alcohol Yes    No
Amount?
Use Street Drugs Yes    No
Use any form of Birth Control Yes    No
Have any Physical Restrictions Yes    No
Cultural/Religious/Discharge Concerns? Yes    No
Have someone to help you when you go home? Yes    No
Have Durable Power of Attorney? Yes    No
Have a living will? Yes    No
Unexpected weight change >10% Yes    No
Past or present domestic violence Yes    No

 Please List
Surgeries
None 
Allergies
None 
Are you Allergic to Iodine / Tape / Band-AIDS or LATEX
 Yes
 No

 Communication
EnglishBlindHard of HearingDeafLearning Impairment
Language  

 Please List
MEDICATIONS: list Name, Dose, and Times per Day

Your information is not visible, submitted or stored in any way on the YourSurgery.Com site.


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