Patient Information
Name
*
Date of Birth
*
.
Month
.
Day
Year
Phone Number
*
Format: (000) 000-0000.
Height
*
Weight
*
Any Allergies:
*
Please include details of what type of reaction you have.
Alcohol Use
*
Yes
No
How Often?
Tobacco Use
*
Yes
No
Packs per Day:
Former Smoker?
*
Yes
No
Scheduled Procedure (Left or Right and Type of Procedure)
*
Doctor Performing:
*
Date of Procedure
*
.
Month
.
Day
Year
List of Past Surgeries (please include any heart surgeries)
*
Current Medications
*
Past Medical History
Heart Problems
*
Heart Attack
Heart Surgery
No Heart Problems
CABG or Stents?
Please include answer with MI or NO MI: Date/Year
Other Heart Problems:
Irregular Heartbeat
*
A-Fib
Pacemaker
Defibrillator
None
High Blood Pressure
*
Yes
No
High Cholesterol
*
Yes
No
Sleep Apnea
*
Yes
No
CPAP?
Yes
No
Breathing Problems
*
COPD
Emphysema
Home Oxygen
Asthma
No Breathing Problems
Diabetes
*
Yes
No
Thyroid Disease
*
Yes
No
Glaucoma
*
Yes
No
Stroke/TIA
*
Yes
No
Date of Stroke:
Seizure
*
Yes
No
Neuro Issues:
*
Parkinson's
Alzheimer's
MS
None
Cancer
*
Yes
No
Cancer Site
Infectious Disease
*
HIV
Hepatitis
TB
MRSA
None
Other Infectious Diseases
*
Yes
No
Other Infectious Disease Type
Problems with Anesthesia
*
Nausea
Vomiting
High Fever
None
Kidney Disease/Issue
*
Yes
No
Kidney Disease/Issue Type
Liver Disease/Issue
*
Yes
No
Liver Disease/Issue Type
Acid Reflux
*
Yes
No
Hiatal Hernia
*
Yes
No
Bleeding or Clotting Issue
*
Yes
No
Bleeding or Clotting Issue Type
Panic Attacks
*
Yes
No
Anxiety
*
Yes
No
Depression
*
Yes
No
Please verify that you are human
*
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