Your Surgery in your own words:

Your Surgeon:

Date of Surgery :
/ /

Demographics

First Name:
  Middle Initial:

Last Name:

Street Address:

City:

State:

Zip Code:

Date of birth:
/ /

Age:

Email Address:

Medical Information

1. Family Doctor:

Did you have a pre-operative history and physical with this doctor within 30 days prior to your surgery?

Yes: No:

2. Do you have any heart problems? (select any that apply)

a. Irregular heart beat: Yes: No:

b. Are you able to walk up two flights of stairs without chest pain, chest pressure or significant shortness of breath?

Yes: No:

c. Heart attack in the past? Yes: No:

Date of heart attack:
/ /

d. Heart murmur or heart valve problems? Yes: No:

e. Pacemaker or internal defibulator? Yes: No:

Name of device manufacturer:

3. Have you ever had a stroke?

Yes: No:

Date of stroke:
/ /

4. Have you ever had a seizure?

Yes: No:

Date of seizure:
/ /

5. Did your doctor ever tell you that you needed to take antibiotics before surgery or a dental procedure?

Yes: No:

6. Are you pregnant?

Yes: No: Unknown:

Date of last menstrual period:
/ /

7. Do you have high blood pressure?

Yes: No:

8. Do you have sleep apnea?

Yes: No:

a. If yes, do you use C-PAP at night? Yes: No:

b. If yes, do you use oxygen at night? Yes: No:

9. Do you have any lung problems?

Yes: No:

a. COPD? Yes: No: If yes, are you on oxygen? Yes: No:

b. Asthma? Yes: No:

c. Require breathing treatments, and/or nebulizers and/or inhalers? Yes: No:

d. Have you ever been treated for TB (tuberculosis) or TB exposure? Yes: No:

e. Have you had an upper respitory infection within the last 2 weeks? Yes: No:

f. Do you smoke? Yes: No:  If yes, how much?

Have you smoked in the past? Yes: No: When did you quit?

10. Have you ever had jaundice or hepatitus?

Yes: No:

11. Do you have kidney, bladder or prostrate problems?

Yes: No:

12. Do you have bleeding problems?

Yes: No:

13. Do you have a history of blood clots?

Yes: No:

14. Have you ever been told by your doctor that you have an immune disorder?

Yes: No:

Name of disorder:

15. Do you have thyroid problems?

Yes: No:

16. Are you diabetic?

Yes: No:

a. If yes, do you take insulin? Yes: No:

a. If yes, what dosage?

17. Do you have glaucoma?

Yes: No:

18. Do you have stomach problems?

Yes: No:

a. Acid reflux, heartburn (GERD)? Yes: No:

b. Hiatal hernia? Yes: No:

c. Ulcers? Yes: No:

d. History of gastro-intestinal (GI) bleeding? Yes: No:

19. Do you have an infectious disease?

Yes: No:

a. Do you have MRSA? Yes: No:

b. Do you have VRE? Yes: No:

c. Do you have C-Diff? Yes: No:

d. Any other? Yes: No:

20. Do you have any problems with anxiety?

Yes: No:

If yes, please explain:

21. Do you drink alcohol?

Yes: No:

If yes, how often?

22. Do you take any illegal drugs?

Yes: No:

23. Is there anything else about your health that you think we should know?

Yes: No:

If yes, please explain:

Anesthesia:

1. Have you ever had anesthesia in your past?

Yes: No:

2. Have you ever had any problems with anesthesia?

Yes: No:

3. Have you ever been told you were difficult to intubate or had a "difficult airway"?

Yes: No:

4. Have you ever been told you have malignant hyperthermia?

Yes: No:

5. Have any of your blood relatives been told they have malignant hyperthermia?

Yes: No:

6. Do you have any loose teeth?

Yes: No:

7. Do you have any capped teeth?

Yes: No:

8. Do you have any dentures or partials?

Yes: No:

Past Surgeries and Year of Surgery:

Current Medications:

Please list all medications that you take every day, including herbals and over-the-counter medications.

A Siouxland Surgery Center nurse will call you to talk to you about what medications to take the day of surgery and what medications to refrain from taking the day of surgery.

Medication 1:

At what time of day/night do you take this medication?

Have you stopped taking this medication? Yes: No:

If yes, when did you stop taking it?

Comments:

Medication 2:

At what time of day/night do you take this medication?

Have you stopped taking this medication? Yes: No:

If yes, when did you stop taking it?

Comments:

Medication 3:

At what time of day/night do you take this medication?

Have you stopped taking this medication? Yes: No:

If yes, when did you stop taking it?

Comments:

Medication 4:

At what time of day/night do you take this medication?

Have you stopped taking this medication? Yes: No:

If yes, when did you stop taking it?

Comments:

Medication 5:

At what time of day/night do you take this medication?

Have you stopped taking this medication? Yes: No:

If yes, when did you stop taking it?

Comments:

If you take more medications, please list below:

Intolerances:

Please list any medication that may have caused you stomach problems in the past or that you could not tolerate.

1.

2.

3.

Medication Allergies:

Please list all medication allergies that you are aware of.
What did the medication do to you when you took it? Hives? Breathing problems? Other?

Preparing for Surgery:

1. Follow all instructions given to you by your surgeon.
2. DO NOT EAT ANYTHING AFTER MIDNIGHT on the night before surgery. This includes mints, hard candy and gum.
3. DO NOT DRINK ANYTHING AFTER MIDNIGHT on the night before surgery. If you are instructed to take any medication on the day of surgery, you may have a small sip of water if necessary to assist in swallowing the medication.
4. Please bring your insurance card and a picture form of identification with you to Siouxland Surgery Center.
5. Due to the fact that you may not be able to shower/bathe/wash hair for a few days after surgery, please bathe or shower and wash your hair prior to surgery.
6. Remove all jewelry and piercings before coming to Siouxland Surgery Centerfor your surgery. Do not bring large amounts of cash or other valuables with you.
7. Remove all nail polish, if possible.
8. You will need a driver to take you home from Siouxland Surgery Center.
9. Please wear loose-fitting clothing.
10. A nurse will contact you within 24 hours prior to your surgery. If you do not hear from us, please call us at (605) 232-3332 or (877) 232-3332 and ask to speak with a Recovery Care Center nurse!

We are looking forward to taking care of you!