First Name * Last Name * Email Address * Address * City * State * Zip * Home Phone Number * Cell Phone Number * Work Phone Number * Age * Date of Birth * Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Height * Weight * Date Scheduled For Surgery * Year Year20192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074207520762077207820792080208120822083208420852086208720882089209020912092209320942095209620972098209921002101210221032104210521062107210821092110211121122113211421152116211721182119 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Doctor * - Select -Richard H. Alfred, M.D.R. Maxwell Alley, M.D.Kaushik Bagchi, M.D.Kelley E. Banagan, M.D.Samuel S. Caldwell, M.D.Robert A. Cheney, M.D.Ernest N. Chisena, M.D.Cory Czajka, M.D.John Czajka, M.D.Shankar P. Das, M.D.Matthew R. DiCaprio, M.D.John A. DiPreta, M.D.Vivek Dutt, M.B.B.S., M.S. (Ortho), Dip. Nat. Board (Ortho)Michael A. Flaherty, M.D.Marc D. Fuchs, M.D.Andrew C. Gerdeman, M.D.Alexander R. Harbin, M.D.Robert J. Hedderman, M.D.Paul P. Hospodar, M.D.Anjum Iqbal, M.D.Hamish A. Kerr, M.D.James Lawrence, M.D.Jordan M. Lisella, M.D.Jeffrey Lozman, M.D.Abigail Mantica, M.D.Patrick G. Marinello, M.D.Andrew S. Morse, M.D.Michael T. Mulligan, M.D.Daniel T. Phelan, M.D.David E. Quinn, M.D.Alexander R. Riccio, M.D.Jared T. Roberts, M.D.Andrew Rosenbaum, M.D.James M. Schneider, M.D.Todd Shatynski, M.D.Joachim J. Tenuta, M.D.Matthew W. Tetreault, M.D.Jon T. Toussaint, M.D.Richard L. Uhl, M.D.Richard R. Whipple, M.D.George Zanaros, M.D.Joseph P. Zimmerman, M.D. Primary Care Physician * What are you having done? * What side? * Please list any medications you are taking orally (including diet pills, prescriptions, over-the-counter medications, vitamins, and herbal remedies) * Allergies * Yes No Allergy List Latex Allergy * Yes No High Blood Pressure * Yes No Chest Pain * Yes No Congestive Heart Failure * Yes No Mitral Valve Disease * Yes No Prior Heart Attack * Yes No Heart Attack Date Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Other Cardiovascular Disease * Yes No If yes, please explain Asthma * Yes No Emphysema * Yes No Shortness of Breath * Yes No Sleep Apnea * Yes No Tuberculosis * Yes No Other Respiratory Disease * Yes No If yes, please explain Anxiety / Depression / Mental Illness * Yes No Hearing Deficit * Yes No Numbness or Tingling * Yes No Seizure Disorder * Yes No TIA / Stroke History * Yes No Residual? Yes No Other Central Nervous System Disease * Yes No If yes, please explain Hepatitis / Jaundice History * Yes No Heartburn / Gastric Reflux * Yes No Diabetes * Type I Type II No Other GI Disease * Yes No If yes, please explain Cancer * Yes No Type Thyroid Disease * Yes No Kidney Disease * Yes No Arthritis * Yes No Arthritis Neck Involvement? Yes No Sickle Cell Disease * Yes No Bleeding Disorders * Yes No Type Do you have a living will or healthcare proxy? * Yes No Pregnant * Yes No Date of last period Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Other Medical Conditions * Yes No If yes, please explain Do you have any open cuts or wounds? * Yes No Family / Self History of Malignant Hyperthermia * Yes No Motion Sickness * Yes No Smoker * Yes No Packs Per Day Quit Smoking Yes No Date Quit Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Alcohol Consumption * Yes No Number of Alcoholic Drinks / Week Recreational Drug Use * Yes No Drug Type Previous Surgeries * Yes No If yes, please list below Difficulties With Anesthesia * Yes No If yes, please explain
