| 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 | Sjogren's | ||
| 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: | |||
