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  • UMMC Preoperative and Preanesthetic Patient Questionnaire
    This questionnaire will help your anesthesia team determine what if any preoperative work up will be needed prior to your surgery and help them gather all available medical information about you Please fill it out as best you can This information will help to avoid any delay in your surgery
  • PRE-SURGERY QUESTIONNAIRE - My Doctor Online
    PRE-SURGERY QUESTIONNAIRE Please complete prior to your Preoperative Medicine (POM) Appt Have you had any recent changes in your health? Yes:  No:  We would like to ask if you have recently had any of the following: Fever:
  • PRE-OPERATIVE SURGICAL QUESTIONNAIRE
    ***Please bring all your medications on the day of surgery and attach pharmacy list DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING PROBLEMS? (select all that apply)
  • PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE - Providence
    filling out questionnaire RN Patient reviewing questionnaire RN Patient Patient Label Heart Vascular Problems Nerve Disease Bleeding Problems Dental Vision Hearing Heart Attack Stroke Easy Bruising Dentures Partial Plate
  • PRE-SURGERY QUESTIONNAIRE - Brigham and Womens Hospital
    Do you have, or have you ever had any problems with your heart?
  • Pre-Operative Patient History Questionnaire - St. Josephs Healthcare . . .
    Do you have a responsible adult to stay with you at home on the night of your surgery if you are going home the same day as your surgery? Where do you expect to go after being discharged home from surgery?
  • PRE-OP SURGICAL QUESTIONNAIRE GENERAL INFORMATION - Halton Healthcare
    keep track of all the medications you are taking It is important to write down everything, including vitamins and supplements, so your healthcare team can provide you with the best possible care Certain medications might interact with another medication on your list; so, it is important that you al and naturopathic products, and or dr tr
  • PRE-OP HEALTH HISTORY PATIENT QUESTIONNAIRE - The Ottawa Hospital
    PRE-OP HEALTH HISTORY PATIENT QUESTIONNAIRE Dear Patient: Please complete this health history questionnaire to the best of your ability and give it to your surgeon’s office team If you are not sure of any answer, check “not sure” You can add details in the “Please specify” box
  • PRE-OPERATIVE PATIENT QUESTIONNAIRE - gghorg. ca
    Any history of stroke, TIA, other brain problems Explain
  • Pre-Operative Questionnaire
    Pre-Operative Questionnaire Once your surgery has been scheduled, please complete this document and scan email the responses to pacu@bethesdacc com Please allow 24-48 hours for a response from our staff as we are working hard to ensure you and all of our patients are attended to If you prefer faxing the information, the fax is 240-800-3641





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