Pre-Admission Testing Prior to Surgery

Address
Allergies
Latex Allergy
High Blood Pressure
Chest Pain
Congestive Heart Failure
Mitral Valve Disease
Prior Heart Attack
Other Cardiovascular Disease
Asthma
Emphysema
Shortness of Breath
Sleep Apnea
Tuberculosis
Other Respiratory Disease
Anxiety / Depression / Mental Illness
Hearing Deficit
Numbness or Tingling
Seizure Disorder
TIA / Stroke History
Residual?
Other Central Nervous System Disease
Hepatitis / Jaundice History
Heartburn / Gastric Reflux
Diabetes
Other GI Disease
Cancer
Thyroid Disease
Kidney Disease
Arthritis
Arthritis Neck Involvement?
Sickle Cell Disease
Bleeding Disorders
Do you have a living will or healthcare proxy?
Pregnant
Other Medical Conditions
Do you have any open cuts or wounds?
Family / Self History of Malignant Hyperthermia
Motion Sickness
Smoker
Alcohol Consumption
Recreational Drug Use
Previous Surgeries
Difficulties With Anesthesia
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