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Wausau Surgery Center
HEALTH HISTORY
Health History to be completed by patient or by parent of minor.
Heart problems / Valve / Stenting / Murmur / Congestive Heart failure / atrial fibrillation, heart attack
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Yes
No
If yes what:
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Yes
No
Stroke
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When?
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Yes
No
Hight blood pressure
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Yes
No
Hyperlipidemia
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Yes
No
Asthma / lung disease / TB / Chronic Obstructive Pulmonary disease
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If yes, what?
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Yes
No
Sleep apnea
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Yes
No
If yes, do you use a CPAP or oral appliance?
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Yes
No
Do you snore?
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Yes
No
Bleeding / clotting problem
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If yes, what?
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Yes
No
Arthritis
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Yes
No
Artificial Joints
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Yes
No
Gerd (Acid Reflux)/ Hiatal Hernia
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Yes
No
Migraines
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Yes
No
Diabetes Diet/Oral/Insulin
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Yes
No
Cancer
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if yes, what?
*
when?
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Yes
No
Kidney / bladder problems / Urinary Tract Infection / Stone / Renal failure
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if yes, what?
*
when?
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Yes
No
Fainting / dizzy spells
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Yes
No
Seizure / epilepsy
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If yes, last seizure?
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Yes
No
Malignant hyperthermia (High fever while under anesthesia)
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Yes
No
Thyroid disease
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Yes
No
Liver disease / hepatitis
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If yes, what?
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Yes
No
Recent cold symptoms
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If yes, what?
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When?
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Yes
No
Anxiety / Depression
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Yes
No
Tested for MRSA/VRE (Skin wound infections)
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When?
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negative
positive
Any other health problems not mentioned?
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Past surgeries or procedures
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Yes
No
Have you had any problems with anesthesia?
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If yes, what?
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Special Needs
Yes
No
Recent falls in last 6 months
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If yes, when:
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Circumstance:
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Yes
No
Do you speak and understand English?
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Preferred language:
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Yes
No
Hospitalizations in the past year
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If yes what were you hospitalized for?
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Yes
No
Do you smoke?
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Pack(s) per day
Yes
No
Second hand smoke exposure
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Alcohol?
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None
Occ.
Daily
We ask that you avoid alcohol and smoking for 24 hours prior to your procedure.
Height:
Weight:
Please fill out
Height:
Weight:
Home Care Assessment
Do you live?
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Alone
With someone in the home
Who is available to help after you are discharged from the center?
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We recommend somebody is with you for the first 24 hours following surgery.
Who will drive you home after the procedure (Your driver must be over 18 years of age)
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Person completing form:
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Person completing form:
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Date Of Surgery
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+
Relationship to patient if patient is a minor or unable to complete form:
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PATIENT MEDICATIONS AND SUPPLEMENTS
Do you take any medications at home?
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Yes
No
Medication Name:
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-
Dose and Frequency:
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-
Allergies and Reactions
Do you have any drug allergies?
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Yes
No
Drug Allergies
🛈
+
-
Reaction
🛈
+
-
Do you have any food allergies?
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Yes
No
Food Allergies
🛈
+
-
Reaction
🛈
+
-
Yes
No
Latex
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If yes, what happens?