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 *
Stroke *
Hight blood pressure *
Hyperlipidemia *
Asthma / lung disease / TB / Chronic Obstructive Pulmonary disease *
Sleep apnea *
If yes, do you use a CPAP or oral appliance? *
Do you snore? *
Bleeding / clotting problem *
Arthritis *
Artificial Joints *
Gerd (Acid Reflux)/ Hiatal Hernia *
Migraines *
Diabetes Diet/Oral/Insulin *
Cancer *
Kidney / bladder problems / Urinary Tract Infection / Stone / Renal failure *
Fainting / dizzy spells *
Seizure / epilepsy *
Malignant hyperthermia (High fever while under anesthesia) *
Thyroid disease *
Liver disease / hepatitis *
Recent cold symptoms *
Anxiety / Depression *
Tested for MRSA/VRE (Skin wound infections) *
When? *
Have you had any problems with anesthesia? *

Special Needs

Recent falls in last 6 months *
Do you speak and understand English? *
Hospitalizations in the past year *
Do you smoke? *
Second hand smoke exposure *
Alcohol? *
We ask that you avoid alcohol and smoking for 24 hours prior to your procedure.
 Height:Weight:
Please fill out

Home Care Assessment

Do you live? *
We recommend somebody is with you for the first 24 hours following surgery.
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PATIENT MEDICATIONS AND SUPPLEMENTS

Do you take any medications at home? *
Medication Name:
Dose and Frequency:

Allergies and Reactions

Do you have any drug allergies? *
Drug Allergies 
Reaction 
Do you have any food allergies? *
Food Allergies 
Reaction 
Latex *