Patient Information Form for Tubal Ligation Reversal
Formulario de Información del Paciente para Reversión de Ligadura de Trompas
Patient Information - Current Legal Name
*
Date of Birth
*
-
Month
-
Day
Year
Age
*
Email
*
Primary Phone Number
*
Format: (000) 000-0000.
Address / Dirección
*
Do you have children? If yes, state their ages.
*
Occupation
*
Current Weight
*
Current Height
*
Blood Type (If not known, type unknown)
*
Name of Physician or Referring Physician if Referred
Phone Number of Physician or Referring Physician if Referred
Format: (000) 000-0000.
Significant Other Information
Date of Birth of Significant Other
-
Month
-
Day
Year
Primary Phone Number of Significant Other
Format: (000) 000-0000.
Email of Significant Other
Please confirm the State you live in
*
Please choose what procedure you desire: / Elija el procedimiento que desea:
*
Tubal Ligation Reversal / Reversión de Ligadura de Trompas
Essure Reversal / Reversión de Essure
Essure Reversal (only removing coils and tube not repaired for pregnancy) / Reversión de Essure (solo se retiran los dispositivos y las trompas no se reparan para el embarazo)
Adiana Reversal / Reversión de Adiana
Adiana Removal (only removing coils and tube not repaired for pregnancy) / Extirpación de Adiana (solo se retiran los dispositivos y las trompas no se reparan para el embarazo)
Full legal name at time of tubal ligation
*
Approximate Date of Tubal Ligation Surgery
*
Name of Hospital where Tubal Ligation was performed
*
Emergency Contact Name and Relationship to Patient
*
Emergency Contact Number
*
Format: (000) 000-0000.
Have you ever received Anesthesia?
*
Yes / Sí
No
Have you received steroid or cortisone medication?
*
Yes / Sí
No
Have you ever had a problem due to Anesthesia? If yes, please provide details.
Have you ever had a sexually transmitted disease? If yes, provide diagnosis, treatment and current status.
Are you taking non-prescription medication or supplements? If so, please specify name, dosage and frequency.
Are you taking prescription medication? If so, please specify name, dosage and frequency.
Do you have any non-surgical problems? If yes, please specify. If no, state no.
*
Do you have any allergies or bad reactions to medicine? If so, please specify. If not, state no.
Do you or have you ever had any issues with anemia, low iron, blood transfusions or any bleeding issues?
*
Yes / Sí
No
Do you have heavy periods?
*
Yes / Sí
No
Do you have a problem with your lungs?
*
Yes / Sí
No
Do you have a respiratory infection?
*
Yes / Sí
No
Do you have blood pressure problems?
*
Yes / Sí
No
Do you have a problem with your liver?
*
Yes / Sí
No
Do you have a problem with your kidneys?
*
Yes / Sí
No
Do you have thyroid disease?
*
Yes / Sí
No
Do you have diabetes?
*
Yes / Sí
No
Do you have HIV?
*
Yes / Sí
No
Do you have Hepatitis B?
*
Yes / Sí
No
Do you have Hepatitis C?
*
Yes / Sí
No
Do you have seizures or epilepsy?
*
Yes / Sí
No
Do you have any eye diseases?
*
Yes / Sí
No
Do you have capped or chipped teeth?
*
Yes / Sí
No
Do you have any neck problems?
*
Yes / Sí
No
Do you or have you ever been diagnosed with sleep apnea or used a CPAP machine?
*
Yes / Sí
No
Ever had muscle weakness?
*
Yes / Sí
No
Ever had a blood transfusion reaction?
*
Yes / Sí
No
Have you ever seen a nerve specialist?
*
Yes / Sí
No
Have you ever had an endometrial ablation?
*
Yes / Sí
No
Do you smoke?
*
Yes / Sí
No
Do you use alcohol?
*
Yes / Sí
No
Do you have a history of drug abuse?
*
Yes / Sí
No
Do you have a healthcare power of attorney and or advance directives?
*
Yes / Sí
No
Do you know what type of ligation was performed?
*
Cautery / Cauterización
Cut / Corte
Banded / Anillado
Clip
Unsure / No estoy segura/o
If you answered “yes” to any of the questions above, please provide additional details.
Have you had any prior surgeries? If yes, please include surgery types and dates.
*
Was your tubal ligation performed during a C-section (open surgery) or a laparoscopy (through the belly button)? If it was a C-section, please specify the date. If it was a laparoscopy, simply state "laparoscopy."
*
Any other health information that you need to disclose?
How many C-sections have you had? ¿Cuántas cesáreas has tenido?
*
0
1
2
3
4
5
Other
Do you have access to your tubal ligation medical records? ¿Tienes acceso a tus registros médicos de la ligadura de trompas?
*
Yes
No
Unsure
Do you need a Spanish speaking representative?
*
No
Yes
PLEASE CONFIRM THE FOLLOWING / POR FAVOR, CONFIRME LO SIGUIENTE
*
I verify that my Body Mass Index (BMI) must be below 37 at the time of my surgery. / Verifico que mi índice de masa corporal (IMC) debe ser inferior a 37 en el momento de mi cirugía.
I verify that I have disclosed all my medical information and understand that if I failed to disclose any information that NCCRM reserves the right to cancel my surgery and I forfeit all financial payments made to NCCRM. / Verifico que he divulgado toda mi información médica y entiendo que si no he divulgado alguna información, NCCRM se reserva el derecho de cancelar mi cirugía y perderé todos los pagos financieros realizados a NCCRM.
Signature / Firma
*
Date of Signature
*
-
Month
-
Day
Year
Submit
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