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Microsoft word - pre-anestheticform.doc

Please fill out this form carefully and completely.
Pasadena Surgery Center
Bring to Pasadena Surgery Center on the day of surgery.
Patient Name: _____________________________ Pro
cedure # 1: ____________________________________________
Height: _____________ Weight: ______________ Pro
cedure # 2: _________________________________
Are you allergic to latex? ( Please circle and notify the nur
se on admission ) Yes No
List Other Allergies:
List ALL Previous Surgeries:
_______________________________________________ _____________________________________________________ __________________________________________ __ ______________________________________________ __________________________________________ __ ______________________________________________ __________________________________________ __ ______________________________________________ Do you take any blood thinners?
Aggrenox
YES Stopped when?
Coumadin
YES Stopped when?
YES Stopped when?
YES Stopped when?
Motrin, etc
YES Stopped when?
Arthritis med NO
YES Stopped when?
List Below ALL your other medications including over-the-counter, vitamins, & herbal supplements.
How taken
How of ten
Reason for taking
Last taken?
Last Taken?
Medication
this medication
Check this box if you do not take any medications
YES NO Substance Use
YES NO Anesth
esia Problems
Answer YES or NO for EACH DISEASE
YES NO YES NO

YES NO Cardiovascular Disease

YES NO Pulmonary Disease
Smoking History:
Valve Disease/Heart Murmur Other: ______________________ YES ______ Packs / Per day YES NO Teeth
Pacemaker/Defibril ator YES NO Endocrine Disease
QUIT WHEN? ___________
YES NO Neurological Disease YES NO Infectious Diseases
_________________________________________________ _________________________________________________ Visit 1 Date: ______________________
YES NO GI Disease
Reviewed by Anesthesiologist ____________________________
Reviewed by Nurse____________________________________________
YES NO Blood Disease
YES NO Kidney Disease
Visit 2 Date: ______________________
Reviewed by Anesthesiologist ____________________________
Reviewed by Nurse ____________________________________________
___________________________________ _____________________
Patient Signature Date

___________________________________ _____________________
Patient Signature

Source: http://www.pasadenasurgerycenter.org/files/Pre-AnestheticForm.pdf

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