Preoperative Assessment and Call Sheet

Before completing your pre-op assessment please read MedStar Health, Inc. Notice of Privacy Practices and Patient Rights and Responsibilities.

To submit your pre-op assessment electronically, please complete the form below. If you prefer to bring a hard copy of the form with you, please print this PDF and bring the completed form with you to your procedure.

* required information

Contact and Basic Surgery Information
Last Name* First Name* MI
Home Phone* Cell Phone Work Phone
 
Name of Surgeon Date of Surgery*  (MMDDYYYY)
Procedure Time of Surgery
  Anesthesia
Sex Age Height Weight BMI if known
Allergies
Are you allergic to any medication or anything that you are aware of?*
If so, please list them.
Have you ever had a reaction to or been told by a physician that you have an allergy to latex or natural rubber products?*
Social History
Do you smoke? If so, how much and how often?
Do you drink? If so, how much and how often?
Do you use any drugs for recreation? What drugs? How much and how often?
Are you or do you think you may be pregnant?
Surgical History
What previous surgeries have you had?
Did you have any problems with anesthesia?*
Have any of your relatives had a serious reaction to anesthesia?*
List and describe any reactions to anesthesia.
Do you take antibiotics prior to having dental work?
Medication
Check here if you are not currently taking any medication.
Please list all prescription (including dose if possible) and over-the-counter medications you are taking. Include herbal supplements, vitamins and over-the-counter medications (e.g., aspirin).
Medical History
Do you have high blood pressure or any heart problems? Please check all that apply.
 High blood pressure  Chest pain (Angina)  Heart murmur  Heart attack
 Pacemaker  Irregular heart beat  Fatigue climbing two flights of stairs or walking two blocks
 Defibrillator
Explanation:
Have you had any problems with your lungs or breathing? Please check all that apply.
 Asthma  Emphysema  Productive cough  Sleep Apnea
Explanation:
Have you been diagnosed with sleep apnea? If no, please answer the following:
Do you snore loudly? Do you often feel tired or sleepy during the daytime?
Has anyone observed you to stop breathing during sleep? Do you have high blood pressure?
Explanation:
Have you had any problems with your blood? Please check all that apply.
 Anemia  Prolonged bleeding  Sickle cell disease  Bruise easily
Explanation:
Do you have any problems with your nerves, muscles or joints? Please check all that apply.
 Seizures  Fainting or dizziness  Strokes  Muscle weakness
 Physical disabilities  Psychiatric illness
Explanation:
Have you had or do you have any problems in any of the following areas? Please check all that apply.
 Diabetes or 'high sugar'  Thyroid disease  Kidney/Bladder  Hepatitis/Jaundice
 Reflux/GI problems  HIV/AIDS  Cancer  Other
Explanation:
Complete Form
Were day-of-surgery instructions given? If not, read them here.
Do you have an Advance Directive?

If you would like us to maintain a copy of your Advance Directive on your medical record, please bring it with you. Although Advance Directives are not honored at MedStar Surgery Center due to the elective nature of all procedures performed here, we will accept and forward a copy to any medical center if needed. If you would like to create an Advance Directive, please print and complete this PDF, and bring it with you. If you have any questions, do not hesitate to discuss them with us.

You must be accompanied by a responsible adult to assist you with transportation needs upon discharge from the surgery center. Your responsible party must remain at the facility during the length of your stay or your procedure will be subject to cancellation. For your safety, the responsible adult should stay with you for the first 24 hours after surgery.

*AGREE - I hereby acknowledge that I have read and understand the MedStar Surgery Center at Lafayette Centre "Ride Policy" - Responsible Adult Must Accompany Patient on Day of Procedure Policy.

Enter additional comments here.
Form Completed by: Completed On Date 11/20/2018

*AGREE - I have read the MedStar Health, Inc. Notice of Privacy Practices and Patient Rights and Responsibilities and wish to submit this information.