LINCOLN SURGERY ENDOSCOPY SERVICES Patient Name:_________________________________________ Your Family Doctor is:___________________________ Reason for today's exam: Height: ________ Weight: _________ Please list all medications, including over-the-counter and herbal remedies below. Medicine Why Taking Medicine Why Taking **List all ALLERGIES including type of allergy reaction: (example: Sulfa-Rash) **Do you take any of the following Anticoagulants? (Circle) Yes No Coumadin Plavix Heparin Xarelto Pradaxa Eliquis LAST TAKEN_________ **Do you take any NSAIDS and/or Arthritis medications? (Circle) Yes No Aspirin Ibuprofen/Advil Aleve/Naproxen Excedrin Toradol Alka Selzer Bextra Celebrex Relafen Feldene Vioxx Indocin Lodine Mobic Other _______________ LAST TAKEN____________ **Do you take any of the following MAO inhibitors? (Circle) Yes No Azilect/Rasagiline Marplan/Isocarboxazid Nardil/Phenelzine Parnate/Tranylcypromine Eutonyl Eldepryl/Emsam/Zelapar/Selegine Do you have or have you had in the past? (Please CIRCLE all that pertain) DIGESTIVE SYSTEM Heart Disease/Problems Rectal Bleeding/Blood in Stools Heart Attack Year_______ Abdominal Pain Rhythm Problem/Irregular Heart Beat Recent Change in Bowel Habits High Blood Pressure Unintentional Weight Gain____ or Loss____ Low Blood Pressure Nausea or Vomiting Pacemaker or Defibrillator Heartburn History of Stroke/TIA Difficulty Swallowing/Food Getting Caught Other________________________________________ Hepatitis RESPIRATORY/LUNGS Crohns or Ulcerative Collitis Breathing or Lung Problems Other____________________________________________ NERVOUS SYSTEM COPD/Emphysema Seizures Sleep Apnea Muscle Weakness/Tingling (Location)_______________ Shortness of Breath Nerve Injury or Paralysis Currently Smoke _________Amount daily Back or Neck Problems Other_________________________________________ Other____________________________________________
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Rev. 9/13, 8/13 (barcode only), 6/13, 11/12,
X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History
5/12 (title only), 9/09, 5/09, 10/07, 4/07
LINCOLN SURGERY ENDOSCOPY SERVICES INFECTIONS Bleeding or Clotting Disorders Diabetic Kidney Problems ORAL CAVITY Thyroid Problems Wear Dentures History of Recreational Drug Use Partial Plate Alcohol Use How Often______________________ Loose Teeth Glaucoma-Narrow Angle Difficulty Opening Mouth FEMALE PATIENTS History or Current Cancer Currently Pregnant Location___________________________________ Currently Breast Feeding Is there any other pertinent information that we need to know? If so please list below Please list past surgeries and approximate year performed: Have you ever had this or any of the following tests before? Please state approximate year. _____Colonoscopy _____Flexible Sigmoidoscopy (Flexi) _____Upper Gastrointestinal Endoscopy (EGD) _____Esophageal Dilation Were there any problems?________________________________________________________________________ Because of sedation, you will not be able to drive or return to work for the remainder of the day. Who will be driving you home following your procedure?_____________________________________________ (If your procedure does not involve sedation please disregard above.) Do you have and Advance Directive (Living Will/Power of Attorney for Healthcare)? Yes_____ No_____ The information I have provided is accurate to the best of my knowledge. Patient Signature:________________________________________ Reviewed by:______________________________________________
Advance Directive on chart ____ yes ____ no
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Rev. 9/13, 8/13 (barcode only), 6/13, 11/12,
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5/12 (title only), 9/09, 5/09, 10/07, 4/07
Unauthorized uses of copyrighted materials are prohibited by law. The PDF file of this article is provided subject to the copyright policy of the journal. Please consult the journal or contact the publisher if you have questions about copyright policy. ABSTRACT : The Venus’ fly trap ( Dionaea muscipula Ellis) is a unique carnivorous plant listed as a Species of Concern within the nativ
North Carolina Society of Oral and Maxillofacial Surgeons Office Anesthesia Evaluation Form A. PERSONNEL 1. ACLS Certificate - (Please have doctor's ACLS Certification available) 2. List of surgical staff's credentials, (OMFSAAP, BLS): B. RECORDS Please have available five charts of patients who have been treated in your office with IV sedation or general anesthesia. Charts m
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LINCOLN SURGERY ENDOSCOPY SERVICES