Pre-Operative Questionnaire

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Name*
FirstLast
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Email*
Medical Information
Age
Weight
Height
Blood Pressure
Pulse
Temperature
Do you wear contact lenses?
- Yes
- No
Do you have dentures, caps or loose teeth?
- Yes
- No
Do you wear a hearing aid?
- Yes
- No
Do you wear a prosthetic device such as a glass eye or an artificial limb?
- Yes
- No
Do you have a pacemaker?
- Yes
- No
Have you had any heart valves replaced?
- Yes
- No
Have you had any joints replaced?
- Yes
- No
Do you have difficulty moving your joints, arms, legs or back?
- Yes
- No
Do you drink alcohol?
- Yes
- No
If yes, how much?
Do you smoke?
- Yes
- No
If yes, how much?
Have you ever had a bad reaction or allergy to a medication or drug?
- Yes
- No
if yes, explain:
Have you ever taken cortisone or steroid preparation within the past two years?
- Yes
- No
If yes, what was the drug name?
If yes, how much did you take?
If yes, when did you take it?
Have you ever had a serious illness?
- Yes
- No
If yes, explain:
Have you ever had any of the following? Select all that apply.
To select multiple conditions, hold the Control key and click.
If you chose Other, explain here:
Do you take any medications or drugs? (example: aspirin, blood thinners, water pills, eye drops, etc.)
- Yes
- No
If yes, name of drug: If yes, how much?
Have you ever had an operation?
- Yes
- No
If yes, please list the type and year starting with the most recent:
Type: Year:
Have you ever had a blood transfusion?
- Yes
- No
Have you, or any family member, had a reaction or death related to a local or general anesthesia?
- Yes
- No
FOR WOMEN ONLY
Is there any possibility that you might be pregnant?
- Yes
- No
If you are having surgery on your reproductive organs, when was your last menstrual period?
SIGN AND DATE
*
- I acknowledge that there is a non-refundable fee of $250.00 if surgery is cancelled without 24 hours notice.
*
- I acknowledge that all of the information on this form is true and accurate.
Today's Date*
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Pre-Operative Questionnaire

Medical Information

FOR WOMEN ONLY

SIGN AND DATE

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