Adult Pre-Op Form

Please take time to fill out our Pre-Operative Information form.  This will allow for a quicker check in time.  All information is secure and will only be used to process your pre-op paperwork.  A Pre-Admission testing nurse will review the submitted information and call you to schedule lab work, or to give your Pre-Operative instructions.

 

Name:       Birthdate: Date of Surgery: 

Surgeon:    Personal Physician:

Planned Surgery:

 

Latex Sensitivity Questionnaire:

Have you ever reacted after handling/using:     1.  Rubber Products (i.e. Balloons)       

     If Yes, Explain Reaction:

2.  Band-Aids / Tape                         

     If Yes, Explain Reaction:

4.  Poinsettia Plant, Bananas, Avocados, Kiwi, Tropical Fruits, Chestnuts   

     If Yes, Explain Reaction:

Allergies and your reaction

 

Other:

1.    2.     3.

4.    5.     6.

 

Current Medications:  Include Dosage, Frequency, am/pm

1.    2.     3.

4.    5.     6.

7.    8.     9.

10. 11.   12.

 

Previous Surgeries/Hospitalizations:

Anesthesia History:

Have you ever had problems with Anesthesia?

If so, Please describe:

Had trouble putting a breathing tube in your throat?

 

Gastrointestinal:   Do you have?

Ulcers or stomach problems (nausea or vomiting)   

Liver problems or jaundice

Hiatal Hernia / Reflux             

 

Cardiovascular:    Do you have?

High blood pressure

Racing or skipped beats.  If yes, explain:

Chest pain or tightness. If yes, explain:

Heart Attack.  If yes, what date:

Bypass Surgery.  If yes, what date:

Stroke

Pacemaker / AICD  

If yes, when was it put in, what brand (e.g. Medtronic, St. Jude, etc.) :

 

 

Do you do any of the following:        

Have you ever smoked? If Yes, current or former?

Alcohol       

Street Drugs

 

Respiratory System:  Do you have?

Asthma/ Sinus Problems

Emphysema/COPD

Chronic or Frequent Cough           

  Sleep Apnea/CPAP

 

Renal System:     Do you have?

Renal/Kidney problems

Dialysis

Gynecological:   Do you have?

Are you Postmenopausal

Regular Periods - Last Period

Tubal / Hysterectomy

 

Miscellaneous:    Do you have?

Diabetes

Bleeding or blood problems

Seizures / Convulsions.  Date of last Seizure:

Do you take blood thinners?

Immune System/Auto Immune Disorder (i.e. HIV, Cancer, MS, Fibromyalgia) 

Do you have a POA / Guardianship

Cancer/Chemo/Radiation

Assistive Devices

Dentures, Partials

Height:       

Weight:      

BMI:      

Daytime Phone number for contact: 

E-Mail:    

Any additional comments or information:

 

Please click the submit button once.  There may be a slight delay after you click on Submit.  You will be taken to a confirmation page once the form is properly submitted.

 

5202 Miller Road
Flint MI 48507