Please fill out this form carefully and completely. Pasadena Surgery Center Bring to Pasadena Surgery Center on the day of surgery. Patient Name: _____________________________ Pro cedure # 1: ____________________________________________ Height: _____________ Weight: ______________ Pro cedure # 2: _________________________________ Are you allergic to latex? ( Please circle and notify the nur se on admission ) Yes No List Other Allergies: List ALL Previous Surgeries:
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Do you take any blood thinners? Aggrenox
YES Stopped when? Coumadin
YES Stopped when?
YES Stopped when?
YES Stopped when? Motrin, etc
YES Stopped when? Arthritis med NO
YES Stopped when? List Below ALL your other medications including over-the-counter, vitamins, & herbal supplements. How taken How of ten Reason for taking Last taken? Last Taken? Medication this medication Check this box if you do not take any medications YES NO Substance Use YES NO Anesth esia Problems Answer YES or NO for EACH DISEASE YES NO YES NO YES NO Cardiovascular Disease YES NO Pulmonary Disease Smoking History:
Valve Disease/Heart Murmur Other: ______________________
YES ______ Packs / Per day YES NO Teeth
Pacemaker/Defibril ator YES NO Endocrine Disease QUIT WHEN? ___________ YES NO Neurological Disease YES NO Infectious Diseases
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Visit 1 Date: ______________________ YES NO GI Disease Reviewed by Anesthesiologist ____________________________ Reviewed by Nurse____________________________________________ YES NO Blood Disease YES NO Kidney Disease Visit 2 Date: ______________________ Reviewed by Anesthesiologist ____________________________ Reviewed by Nurse ____________________________________________ ___________________________________ _____________________ Patient Signature Date ___________________________________ _____________________ Patient Signature
Do not use these oils if you have the following health problems: Do not use: Basil, Eucalyptus, Fennel, Hyssop, Sage, Rosemary• High Blood pressureDo not use: Red Thyme, Hyssop, Pine, Rosemary, Sage • HypoglycemicDo not use: Basil, Birch, Camphor, Cassia, Cedarwood, Clary Sage, Clove Bud, Coriander Fennel, Sweet Hyssop, Jasmine, Juniper, Lemon Marjoram, Myrrh, Peppermint, Rose, Rosemary, S
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