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Coffeyville Regional Medical Center

Pre-Operation Health Assessment

Please fill out this form if you are coming to CRMC for a surgical procedure.
Please answer the following questions to the best of your knowledge based upon YOUR health unless otherwise indicated. Only the items marked with an * must be answered. The others are optional. It will be helpful to us if you answer every one you can.
About You
* Name
First and Last Name
* Date of Birth
Please use MM/DD/YYYY for example 01/30/1950
About your Doctor and Procedure
* Procedure
What type of procedure/operation are you coming in for?
  Date of Procedure
What day are you scheduled to come in?
* Doctor for Procedure
Who is the doctor/surgeon that you will see?
About your health
  Why are you having this procedure or what symptoms do you have?
* Age
  Height
  Weight
* Are you allergic to any drugs? Yes     No    
  If yes, please describe drug allergies.
Please include the drug and type of reaction it caused.
* Are you allergic to any foods? Yes     No    
  If yes, please describe food allergies.
Please include the food and type of reaction it caused.
* Are you allergic to latex? Yes     No    
  If yes, please describe latex allergy reaction.
  Current Medication
Please include name, dosage, number of times taken per day and what time of day taken. Please include over the counter medications and any supplements.
  Do you take any of the following medications Aspirin or Coumadin or Plavix
Arthritis medications
Cortisone or other steroids
Herbal supplements
Diet pills in the past 6 months
History of Recreational Drugs
  Surgical history
Please include name and date of procedure, as well as any complication.
  Have you ever had any complication from Anesthesia? Yes     No    
  If yes, please explain
  Any blood relative have high fever or other complication during surgery or anesthesia? Yes     No    
  If yes, please explain
  Respiratory
Please check all that apply.
Ashtma
Bronchitis
Emphysema/COPD
Frequent respiratory infections
Pneumonia
Sinusitis
Home oxygen use/nebulizers/c-pap/bi pap
Tuberculosis
A "cold" in the last two weeks
Lung cancer
  Do you currently smoke? Yes     No    
  If you do smoke, how much?
  Did you used to smoke? Yes     No    
  When did you quit?
Approximate date.
  How much did you used to smoke?
  Cardiac History
Please check all that apply to your health history
Hypertension (high blood pressure)
Heart attack
Cardiac stents or angiograns in the past 6 weeks
Cardiac stents or angiograns in the past 6 months
Heart murmur
Heart disease (high cholesterol)
Poor circulation
Sickle cell anemia
Pacemaker
Rheumatic fever
Congestive Heart Failure (CHF) or ankle swelling
Chest pain or angina
Irregular heart beat or palpitations
MVP - Mitral Valve Prolapse
  If do have Mitral Valve Prolapse (MVP), do you take antibiotics before you go to the dentist? Yes     No    
  Systemic
Please check all that apply to your health history
Cancer
Diabetes
"Black outs"
Stroke
Epilepsy or history of seizures
Any neurologic disease
Hepatitis or Jaundice (yellowing of the sking)
Physical restrictions or limitations
Thyroid - High
Thyroid - Low
Kidney or Bladder
Gastrointestinal Disorders
Psychiatric History
  Do you have a history or or are currently treated for
Please check all that apply to your health history
MRSA
C-Diff
VRE
Lice
  If yes, when and where?
If yes to MRSA, C-Diff, VRE or Lice.
  How much beer or alcohol do you consume weekly, or what is your history of usage?
  Do you have any loose or capped teeth? Yes     No    
  Do you wear dentures? Yes     No    
  Is it possible that you may be pregnant? Yes     No    
  Have you had a tubal ligation? Yes     No    
  Please list any physical limitations.
* Are you having pain? Yes     No    
  If yes, please describe painful areas.
Pain Assesment
Using a Pain Scale where 0=none to 10=worst possible pain, please rate the following as it applies to your recent health.
  What is your current pain rating? 0     1     2     3     4     5     6     7     8     9     10    
  What was your worst pain you have experienced? 0     1     2     3     4     5     6     7     8     9     10    
  What is the best pain you have experienced? 0     1     2     3     4     5     6     7     8     9     10    
  What is an aceptable pain level? 0     1     2     3     4     5     6     7     8     9     10    
  Please describe the quality of the pain.
Is it sharp pains, dull aching, etc...
  What is the onset, duration and variations of the pain?
If it comes and goes, how does it start, how long does it last, is it always the same?
  How do you express the pain?
Does it make you cry, irritable, yell, grin and bear it, etc...
  How do you relieve the pain?
  What causes the pain to increase?
  What else does the pain effect?
  Are there any other symptoms that accompany the pain?
For example, vision or hearing problems, nausea, dizziness, etc...
  How does pain effect your sleep?
  How does pain effect your appetite?
  How does pain effect your physical activity?
  How does pain effect your relationship with others?
  How does pain effect your emotions?
  How does pain effect your ability to concentrate?
  Have you had any of these Flu like symptoms recently?
Fever of 100 or greater
Cough
Sore Throat
Nausea
Vomiting
Diarrhea
Body Aches
  If you got a Flu shot this season, approximately when was it?
If you didn't get a seasonal Flu shot this season just type in NO.
  If you got a H1N1 shot this season, approximately when was it?
If you didn't get a H1N1 Flu shot this season just type in NO.
  If you got a Pneumonia Vaccine shot, approximately when was it?
If you didn't get a Pneumonia Vaccine shot just type in NO.
  Are you over age 65? Yes     No    
  If you've had Tuberculosis, approximatley when were you treated?
If you've never had Tuberculosis enter NO, otherwise please give the approximate date you were treated.
  Do you have any of the following symptoms? Fever
Chills
Weight Loss
Night Sweats
Cough
Blood in Sputum
  If you have or had Tuberculosis, what is it's status? Active     Remission    
  Has anyone in your family had Tuberculosis? Yes     No    
  Are there any other medical conditions not mentioned above?
  Are there any questions that you would like to have answered by our anesthesia team at this time?