Patient Medical Information Form - Ingalls Same Day Surgery

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	Patient Medical Information Form
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Please complete this form prior to your arrival and bring it with you on your surgical appointment.

*Name:
*Date of Birth:
Surgeon:
*Surgery or Procedure:
*Reason for Surgery or Problem:

Medical History: Please complete whether you have any problems or issues.
Lung Asthma or Bronchitis:	Yes No
Allergies:	Yes No
Diabetes:	Yes No
Heart Disease:	Yes No
Describe any heart iregularities:	Yes No
High Blood Pressure:	Yes No
Stroke or Seizures:	Yes No
Kidney Disease:	Yes No
Liver Disease:	Yes No
Thyroid Problem:	Yes No
Stomach - GI:	Yes No
Bleeding Disorders:	Yes No
Are you pregnant?	Yes No
Family reaction to anesthesia:	Yes No
Do you drink alcohol or take recreational drugs?	Yes No
Smoke Cigarettes:	Yes No
Packs per day:
Number of years:

Nutritional Needs:

Physical Impairment:

Special Needs:

Please list your previous surgeries:

Please list the medications your take:

Please tell us if there are special concerns or needs that you would like us to know: