PRE-OPERATIVE EVALUATION FORM
PHONE NUMBER WHERE YOU CAN BE REACHED
CELL OR PRIMARY #___________________________
- - - - - - - - PATIENT LABEL- - - - - - - - -
SECONDARY #________________________________
PROCEDURE:___________________________________________________
DATE OF PROCEDURE:________________________
ALLERGIES:___________________________________________________________________________________________________
HEIGHT:_________FT_________INCHES
WEIGHT:_____________LBS
YES
NO
Have you ever had a seizure?
YES
NO
Have you ever had a heart attack, congestive heart failure or a stroke?
YES
NO
Do you take blood thinners?
YES
NO
Have you had cardiac stents placed in the last year?
YES
NO
Do you get short of breath or have chest pain when climbing a flight of stairs, or while
performing light house work? (e.g. Cleaning, Vacuuming and Dusting?)
YES
NO
Do you have diabetes or take diabetic medications? (e.g. Oral Medications or Insulin)
YES
NO
Do you have any breathing problems such as Asthma, COPD, and Emphysema?
If yes, do you use an inhaler?
YES
NO
Do you require supplemental oxygen?
If yes, how often?
YES
NO
Do you have sleep apnea?
If yes, do you use a C-PAP or Bi-PAP?
YES
NO
Have you ever been diagnosed with kidney or liver disease?
YES
NO
Have you or any family member had a problem with Anesthesia? Not including Nausea & Vomiting.
YES
NO
Do you have a respiratory reaction to Latex?
INITIAL:
DUE TO MEDICATIONS GIVEN DURING MY VISIT, I AM AWARE THAT I CAN NOT DRIVE FOR AT LEAST 24 HOURS.
I AM ALSO AWARE THAT I MUST HAVE A RESPONSIBLE ADULT ACCOMPANY ME HOME.
PATIENT SIGNATURE: _________________________________________
DATE:_______________________
FORM REVIEWED BY:__________________________________________
DATE:_______________________