Pre-Procedure Screening
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person completing form:
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Patient
Parent of Minor/Legal Guardian
Medical Power of Attorney
Please check YES if any of the below questions apply to you:
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Rows
No
Yes
Currently on a Blood Thinner
History of an Implanted Device
(Pacemaker, Defibrillator, Spinal Stimulator)
Heart Valve Disease
Require Antibiotics for Dental Work
Decreased Immune System
(Leukemia, Lymphoma, Low Blood Cell Count, Chemotherapy, Diabetes)
History of Skin Infections
History of Infectious Disease
(HIV, Hepatitis B, Hepatitis C)
Currently on an Antibiotic
History of Antibiotic Allergy
History of Adhesive Allergy
Tendency to Feel Woozy, Light-Headed, or Pass-Out with Procedures
If you answered YES to any questions above, please include details below.
Submit
Should be Empty: