Surgery Center

Pre-Operative Nurses Assessment

*Surgeon:

*Procedure:

*Patient Name:

Person completing form:

Relationship to Patient:

*Phone:

Cell Phone:

Today's Date:

*Age

Height:

Weight:

Sex:

ALLERGIES: Do you have any allergies relating to the following?

Medication:

Food:

Latex:

Allergy	Reaction

Add another allergy

MEDICATION:

List all names and doses of ALL medication you take (include herbals and non-prescription/over the counter drugs):

Medication	Dose / How Often

Add another medication

Have you had any of the following cardiac tests within the past 2 years?

EKG

When and Where?:

Physician Name:

Echocardiogram (ultrasound of your
heart)

When and Where?:

Physician Name:

Stress Test

When and Where?:

Physician Name:

Have you ever had a CARDIAC CATHETERIZATION?

When and Where?:

Physician Name:

Do you have an implantable
defibrillator ?

You will need to have this device turned off just prior to your operation

Please ask your surgeon and/or cardiologist when you should stop taking ASA, Plavix, Coumadin, Lovenox, or any other blood thinners.

Have you had any blood work done in the past 30 days?

Type of Test:

Approx. Date & Place:

Do you take Herbal or appetite suppressants

These products must be stopped 2 weeks prior to your operation

Do you have any history of MRSA, Hepatitis, or other infections?

When?

Advance directive (i.e. living will):

If you have one, please bring it with you on the day of your surgery. Federal law requires that we ask if you have executed an Advance Directive. Should an emergency situation occur during your treatment, we will initiate resuscitative or stabilizing measures before transferring you to a hospital for admission. It is not required that you have an Advance Directive, but if you would like further information regarding Advance Directives and/or would like to obtain one, please visit the following website:

www.aging.dhr.georgia.gov and select “Publications”

Other Comments:

Surgery Center

Pre-Operative Nurses Assessment

ALLERGIES: Do you have any allergies relating to the following?

MEDICATION:

Have you had any of the following cardiac tests within the past 2 years?

*You will need to have this device turned off just prior to your operation*

*These products must be stopped 2 weeks prior to your operation*

You will need to have this device turned off just prior to your operation

These products must be stopped 2 weeks prior to your operation