Pre Operative Clearance Intake
Full Name
*
First Name
Last Name
Email Address
*
Date of Birth
*
Marital Status
*
Phone Number
*
-
Area Code
Phone Number
How do you prefer to be contacted?
Height
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Weight
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Current Health Conditions
*
Past Medical History
*
Diabetes
Hypertension
Asthma
Kidney Disease
STI
Autoimmune Disease
Cardiac Disease
Bleeding or Clotting Disorder
Edema/Swelling
Pulmonary Edema
Current Pregnancy
Irregular Heart Rhythm
Heart Failure
Cerebrovascular Disease or Stroke
Artificial Heart Valve
Congenital Heart Disease
Heart Murmur
Anaphylaxis
Family History of Malignant Hyperthermia
I have a history of Anesthesia Reaction/Complication
Coronary Artery Disease
Renal Failure
Liver Disease or Hepatitis
Heart Attack
Fainting or Dizziness
Sleep Apnea
Thyroid Disease
Anemia
Tuberculosis
Heartburn or Reflux
Osteoporosis
Anxiety or Depression
Rheumatic or Scarlet Fever
Sickle Cell Disease
Cancer, Radiation, or Chemo
Epilepsy or Seizures
I have had none of the above conditions and will report any medical history not listed above below.
Additional Medical History or Conditions not listed above:
*
Are you currently taking any medication?
*
Yes
No
Medication List
Do you have any medication allergies?
*
Yes
No
Not Sure
Please List Medicine and Enviromental Allergies
Family History (1st Degree Relatives Only) Parents, Siblings, Children
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Emergency Contact
*
Previous Surgeries and Hospitalizations
*
Anything else that we need to know to insure that you have an optimal experience:
Are you taking blood thinners or Aspirin
*
Yes
No
For Women, the First Date of your Last Menstrual Period
*
My signature indicates that I have disclosed my medical history in it’s entirety and answered all questions completely and accurately:
Submit
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