High blood pressure? Yes No *

Heart Stents? Yes No

How many stents?

Irregular Heartbeat? Yes No

Specify irregular heartbeat

Pacemaker? Yes No *

AICD? Yes No

AICD Manufacturer / Representative Phone#

Asthma? Yes No

Asthma Symptoms

Pneumonia? Yes No

COPD (Chronic Obstructive Pulmonary Disease) Yes No

Can you walk up a flight of stairs?

Do you use oxygen? (how much)

Recent Cough/Cold/Flu (past 2 weeks) Yes No

Is it difficult for you to lay flat for 20 min? Yes No

Explain, why its difficult?

Medical Implants? Yes No

Specify Implants (pins, screws, stents, etc.)

Diabetes? Yes No

Specify Diabetes Treatment Insulin
Oral Agent
Diet Controlled

Stroke? Yes No

Specify when you had your stroke and if you have any residual deficits (speech, difficulty swallowing, weakness, etc.)

Seizure? Yes No

Treatment and date of last seizure

Other Major Medical Issues

Date of LMP (if applicable) ...

Allergies: Drug, Food, Latex, Environmental? (include reactions)

Medications? (OTC, ASA, Herbal Supplements, Vitamins, Inhalers) - specify douse, route and frequency.

Previous Surgeries

Do you have adverse reactions to anesthesia? Yes No

Specify reactions to anesthesia

Language Issues? Yes No

Do you have Advanced Directive? Yes No

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