subject_line
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
*
Yes
No
If yes what:
*
Yes
No
Stroke
*
When?
*
Yes
No
Hight blood pressure
*
Yes
No
Hyperlipidemia
*
Yes
No
Asthma / lung disease / TB / Chronic Obstructive Pulmonary disease
*
If yes, what?
*
Yes
No
Sleep apnea
*
Yes
No
If yes, do you use a CPAP or oral appliance?
*
Yes
No
Do you snore?
*
Yes
No
Bleeding / clotting problem
*
If yes, what?
*
Yes
No
Arthritis
*
Yes
No
Artificial Joints
*
Yes
No
Gerd (Acid Reflux)/ Hiatal Hernia
*
Yes
No
Migraines
*
Yes
No
Diabetes Diet/Oral/Insulin
*
Yes
No
Cancer
*
if yes, what?
*
when?
*
Yes
No
Kidney / bladder problems / Urinary Tract Infection / Stone / Renal failure
*
if yes, what?
*
when?
*
Yes
No
Fainting / dizzy spells
*
Yes
No
Seizure / epilepsy
*
If yes, last seizure?
*
Yes
No
Malignant hyperthermia (High fever while under anesthesia)
*
Yes
No
Thyroid disease
*
Yes
No
Liver disease / hepatitis
*
If yes, what?
*
Yes
No
Recent cold symptoms
*
If yes, what?
*
When?
*
Yes
No
Anxiety / Depression
*
Yes
No
Tested for MRSA/VRE (Skin wound infections)
*
When?
*
negative
positive
Any other health problems not mentioned?
*
Past surgeries or procedures
*
Yes
No
Have you had any problems with anesthesia?
*
If yes, what?
*
Special Needs
Yes
No
Recent falls in last 6 months
*
If yes, when:
*
Circumstance:
*
Yes
No
Do you speak and understand English?
*
Preferred language:
*
Yes
No
Hospitalizations in the past year
*
If yes what were you hospitalized for?
*
Yes
No
Do you smoke?
*
Pack(s) per day
Yes
No
Second hand smoke exposure
*
Alcohol?
*
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?
*
Alone
With someone in the home
Who is available to help after you are discharged from the center?
*
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)
*
Person completing form:
*
Person completing form:
*
Date Of Surgery
*
Relationship to patient if patient is a minor or unable to complete form:
*
PATIENT MEDICATIONS AND SUPPLEMENTS
Do you take any medications at home?
*
Yes
No
Medication Name:
Dose and Frequency:
Allergies and Reactions
Do you have any drug allergies?
*
Yes
No
Drug Allergies
Reaction
Do you have any food allergies?
*
Yes
No
Food Allergies
Reaction
Yes
No
Latex
*
If yes, what happens?