General Information: Step 1

This section contains questions regarding your Contact and Surgery Information. Please note that fields marked in orange or bolded are mandatory.

Contact Information
Surgical Information

Health Assessment: Step 2

This section contains questions regarding your Health Assessment. Please note that fields marked in orange or bolded are mandatory.

Prior Surgeries & Anesthesia Screening
Pediatric
Cardiac & Circulation
Respiratory
Nutrition Metabolic Pattern
(Diabetes type 1)
(Diabetes type 2)
or
Gastrointestinal
Urinary
Male Patients:
Female Patients:
Other Cancers
Cognitive Perception
Communicable Diseases
Pain
Fall Assessment
Summary of health conditions
Communication
Education Needs
Discharge planning

Who will be driving you home?
If you are having Anesthesia the person taking care of you must be here during your visit.
Once released, you will need assistance overnight. You will not be released to a taxi cab. Your driver must be at least 18 years of age

Additional Info
If you have an advance directive you may bring it, and a copy will be placed in your chart

Medications and Allergies: Step 3

This section contains questions regarding your Medications and Allergies. Please note that fields marked in orange or bolded are mandatory.

Medication Reconciliation List
Medication History: Include herbal / alternative, supplemental, and non-prescription (over-the-counter) medications.
Current Medication
Dosage
(mg/ml)
Route
Frequency
(BID/TID/QD)
Allergies / Intolerances
NOTE: Please select Reaction to your allergy.
Medication
Reaction
Any Additional Reaction?