Pre-Surgery Health Questionnaire

Please fill out this pre-surgery questionnaire; when you are finished, please hit the "send" button, and the form will be sent to Physicians' Surgery Center Business Office Manager, Joyce Doege. This will expedite your surgery and help us to service you better.
These questions will be used to evaluate your medical status in relation to anesthesia. Check each question YES or NO. If YES, please explain.

Name/Date:


Are you taking any medication(s), herbs, or nutritional supplements?
Yes No
Please list:


Are you being treated for any medical problems, or had any recent illness not associated with this surgery?
Yes No
Please explain:


Are you allergic to anything (medicine, adhesive tape, etc.)?
Yes No
If so, what?:


Have you ever had surgery before?
Yes No
If yes, where, when, and what type?:


Have you or any blood relative had a reaction to an anesthetic?
Yes No
Please explain:


Do you have any physical impairment which limits the motion of joints, back, arms, or wear a device such as a hearing aid, glass eye, artificial limb, etc.?
Yes No
Please explain:


Do you have difficulty opening your mouth or moving your head or neck?
Yes No

Do you have a cold or any other acute illness?
Yes No

WOMEN: Is there any possibility you are pregnant?
Yes No
When was your last menstrual period?:



Have you ever had any of the following? If so, please check:

Bleeding tendency
Hepatitis, jaundice, liver trouble
Diabetes
Glaucoma
Lung disease, TB
Asthma or wheezing
Emphysema or bronchitis
Angina, chest pain
Sickle cell disease
Irregular heart beat
High blood pressure
Epilepsy, convulsions, stroke
Mental illness
Alcohol/drug addiction or withdrawal
Other serious illness not mentioned above

When you have completed this form to the best of your knowledge and are satisfied that you understand the questions, please click "send" below. Thank you.


Russ Greene, R.N.
Administrator
Joyce Doege, B.S.
Business Office Manager
Vicki Wycoff, R.N.
Patient Care Manager


Please note: survey form is completely confidential and is submitted directly to our business office manager via artworksadvertising server, our marketing and public relations firm.