Local /Pre-op form
Pre-Op Instructions: Arrive 1.5hr before surgery time unless told otherwise by our office. Wear comfortable clothing. Bring your photo ID, insurance card(s) and Covid vaccine card. Leave valuables at home. Continue medications as prescribed unless told otherwise by your surgeon\prescriber. If you develop respiratory/COVID symptoms before your surgery, please contact us at 419-578-7500.
Email
First Name
Last Name
Date of surgery
What time were you told your surgery would start?
Please confirm the procedure/body part being operated on.
40
List if you have the following: Glasses, contacts, hearing aids, dentures. If none, enter "none"
40
What is your height?
20
What is your weight?
20
Check all that apply
History of heart attack, coronary artery disease, congestive heart failure
Pacemaker/AICD (defibrillator)
Angina / chest pain
High blood pressure
Hyperlipidemia - high cholesterol/triglycerides
Bleeding, clotting - genetic in nature
Diabetes
Asthma
COPD - emphysema
Sleep apnea / using a CPAP or BIPAP
URI/ Fever
GERD - gastro esophageal reflux disease
Hiatal Hernia
Ulcers / GI bleeding
Renal disease - kidneys
Dialysis / CAPD - Continuous Ambulatory Peritoneal Dialyses
Liver disease
Hepatitis, AIDS
Cancers - please complete form below
TB
MS - multiple sclerosis
Lupus
Cerebral palsy
Muscle disease
Chronic pain - please complete form below
Thyroid
Epilepsy / Seizures - please complete form below
CVAs / TIAs - stroke or mini stoke
ADD / ADHD
Depression / Anxiety
Skin integrity - eczema, psoriasis, rash - please complete form below
DVT / PD, PE - pulmonary emboli
Family history of PE - pulmonary emboli
Had Covid-19 in the last three months
Possibility of pregnancy?
Do smoke?
20
Choose an option
Never
Quit
Current smoker less than one pack/day
Current smoker more than one pack/day
Do you drink alcoholic beverages? If yes, how much?
Do you exercise? What do you do for exercise?
40
Do you have shortness of breath on exertion?
Do you use a cane, crutches, walker, wheelchair?
20
Please list ALL previous surgeries with month\year
100
Have you or a family member every have issues with anesthesia?
Cancer - if you answered YES, please list type and where on your body (if applicable)
Chronic pain - please list type: arthritis, fibromyalgia, etc. (if applicable)
Epilepsy/Seizures - please list date of last seizure (if applicable)
20
Skin integrity - list TYPE and LOCATION on your body (if applicable)
Please list all MEDICATIONS you take along with the DOSAGE and how often (x/day, month, as needed)
Do you have a LATEX allergy? Please provide symptoms.
List all MEDICATION ALLERGIES as well as your REACTION to them
Received vaccine Covid-19
Yes
No
Covid-19 Vaccine Booster - please list date(s) if applicable
Recent exposure to Covid-19 (last two weeks)
Yes
No
Recent experience of fever, cough, loss of taste/smell
Yes
No
Female patients - date of last menstrual cycle
Upload File - Medication List or other pertinent information
Select a File
Submit
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