SCOPE Clinic – Patient Screening Form
Please fill out:
Name:
Gender:
Date of Birth:
Your Height:
Your Weight:
Daytime Phone #:
Home Phone #:
Do you have any of the following conditions?
Y
N
Y
N
Please describe diagnosis where possible:
Heart condition
Lung condition
Stroke/TIA
Liver Disease
Kidney condition (except stones)
Diabetes requiring insulin
Malignant Hyperthermia
Severe reaction to anesthetics
Are you on any blood thinners?
Coumadin/Warfarin
Plavix
Aggrenox
Ticlid/Ticlopidine
Other:
On physical exertion, do you experience the following symptoms?
Y
Angina/Chest Pain
Shortness of Breath
N