Online Patient Form

Date
Pre-Registration Date
YYYY dash MM dash DD
Date Of Surgery
YYYY dash MM dash DD
Personal Information
First Name*
Race
Middle Name*
Sex
Last Name*
Marital Status
Maiden Name
Home Phone
Date Of Birth
YYYY dash MM dash DD
Cell Phone
SS #
Best Number To Reach You At
Email Address*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer Name
Employer Phone
Spouse / Parent
First Name
Last Name
SS #
Date Of Birth
YYYY slash MM slash DD
Employer Name
Employer Phone
Visit Information
Is this visit due to an accident?
Explain
Do you have an Advanced Directive or Living Will?
Patient Permission to Leave Message on Machine or with Family Member?
INSURANCE INFORMATION
Insurance Company
Contract Number
Group Number
Insurance Address (If Known)
Insurance Phone # (If Known)
MEDICAL INFORMATION
Height
Weight
Pharmacy
List All MEDICATION Allergies and Reactions
List All FOOD Allergies and Reactions
Are you allergic to BANDAIDES, TAPE, or LATEX?
Do you take BLOOD THINNERS or DIET MEDICATION?
List all medications you are taking including:
PRESCRIPTIONS, OVER-THE-COUNTER, VITAMINS, INHALERS, or NEBULIZERS
Name of Medicine Dosage Frequency Last Taken
Family Dr.
Heart Dr.
Lung Dr.
Have you or any BLOOD RELATIVES ever had a problem or severe reaction to ANESTHESIA?
If so who and reaction:
Have you ever been tested and told that you have SLEEP APNEA?
Do you use a CPAP?
Is your sleep apnea mild, moderate, or severe
MEDICAL HISTORY/REVIEW OF SYMPTOMS
Cardiovascular
- None
- High Blood Pressure
- Heart Attack/Coronary
- Heart Stent
- Angina/Chest Pain
- Poor Circulation
- Irregular Heart Beat
- Pacemaker/AICD
- Valve Prolapse
- Coronary Bypass
- Poor Exercise Tolerance
- Open Heart Surgery
- Heart Valve Disease
- Congestive Heart Disease
Respiratory
- None
- COPD
- Emphysema
- Asthma
- Oxygen Use
- Sleep Apnea
- CPAP use
- Resp. Infection
GI/Endocrine
- None
- Acid Reflux
- Peptic Ulcers
- Irritable Bowel Syndrome
- Hepatitis
- Diabetes
- Hypoglycemia
- Thyroid Disease
- Obesity
Neuromuscular
- None
- Headaches
- Stroke
- Seizures
- Parkinson
- Depression
- Anxiety
- Fibromyalgia
- Alzheimer's
- Arthritis/Gout
- Mental Illness
Other Cardiovascular Problems:
Other Respiratory Problems:
Other GI/Endocrine Problems:
Other Neuromuscular Problems:
If you chose yes for hepatitis, what type?
GU/GYN
- None
- Kidney Disease
- Incontinence
- Prostate Problems
- Interstitial Cystitis
- Urinary Tract Infection
- Pregnant
- Last Menstrual Cycle
HemeOnc
- None
- Anemia
- Cancer
- Leukemia
- Bleeding Disorder
- Sickle Cell Disease/Trait
- HIV
Anesthesia/Airway
- None
- Family History of Anesthetic Problems
- Previous Anesthetic Complications
- Maligant Hyperthermia
- Malignant Hyperthermia
- Severe Nausea
- Dentures/Partials
Pediatric
- None
- Recent URI Illness
- Prematurity
- Congenital Anomaly
- Apnea
Other GU/GYN Problems:
Other Heme/Onc Problems:
Other Anesthesia/Airway Problems:
Other Pediatric Problems:
Comments on Positives or Symptoms/Conditions Not Listed:
MISCELLANEOUS
Alcohol Use
- None
- Weekly
- Daily
- Occasionally
Drug Use - Type
Drug Use - Last Used
Tobacco Use - Packs Per Day
Tobacco Use - How Long Have You Smoked?
Tobacco Use - How Long Since You Have Quit?
Are you on a special diet?
- Yes
- No
Any unexpected weight loss?
- Yes
- No
Any problems swallowing or chewing?
- Yes
- No
Any religious/spiritual beliefts that could affect care?
- Yes
- No
If yes, please specify
SURGICAL HISTORY
SURGICAL HISTORY
- Aneurysm
- Appendix
- Rectal
- Bladder
- Kidney
- Kidney Stone
- Back
- Neck
- Breast
- Knee Replacement Left
- Knee Scope Left
- C-Section
- Ear Tubes
- Cataracts
- Tubal Ligation
- Carpal Tunnel
- Gallbladder
- Colon
- D And C
- Hysterectomy
- Laparoscopy
- Hernia Repair
- Hemorrhoid
- Hip Replacement
- Mastectomy Right
- Pacemaker
- Lung
- Prostate
- Shoulder
- Knee Replacement Right
- Knee Scope Right
- Sinus
- Tonsils
- Thyroid
- Vasectomy
- Mastectomy Left
- Stomach
- Open Heart
- Hiatal Hernia Repair
Other surgical histories:
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