Pre-Operative Patient Form

First Name

Last Name

Phone

Email

Do you see a Cardiologist (Heart Doctor)?

Yes

No

Name of Physician and Location:

Have you ever been diagnosed with hypertension?

Yes

No

Current Blood Pressure

Do you take blood pressure medication and/or diuretics (ex. Aldactone, Bumex, Lasix, Zaroxolyn)?

Yes

No

Do you take a blood thinner (ex. Coumadin, Plavix, Xarelto, Eliquis)?

Yes

No

Have you ever had a blood clot in your legs (DVT) or a blood clot in your lungs (PE)?

Yes

No

Describe:

Do you see a Nephrologist (kidney doctor)?

Yes

No

Name of Physician and Location:

Do you have diabetes?

Yes

No

Most recent HbA1c:

Do you receive dialysis?

Yes

No

Do you take weight loss medication or GLP-1 Agonist (Byette, Bydureon, Adlyxin, Wegovy, Ozempic, Rybelsus, Saxenda, Victoza, Trulicity, Mounjaro)?

Yes

No

Name of medication:

Do you see a Pulmonologist (lung doctor)?

Yes

No

Name of Physician and Location:

Are you current or past tobacco user (ex. Cigarettes, vape, chewing tobacco)?

Yes

No

How long?

Do you see a Neurologist (brain doctor)?

Yes

No

Name of Physician and Location:

Do you take narcotic pain medication on a regular basis?

Yes

No

Do you see a Hematologist (blood doctor)?

Yes

No

Name of Physician and Location:

Do you have any bleeding/clotting disorders (Von Willebrand's, Sickle Cell, Thrombocytopenia, etc.)?

Yes

No

Have you or any family members ever experience any complications with anesthesia (ex. Malignany Hyperthermia)?

Yes

No

Please explain:

Pre-Oper­a­tive Patient Form

Pre-Operative Patient Form