Pre-Operative Exam Assessment Form
Please complete this assessment to help us prepare for your upcoming procedure. This form covers essential pre-operative information and a brief review of symptoms and readiness.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Reason for Pre-Operative Assessment
*
Scheduled surgery
Diagnostic procedure
Follow-up
Other
Do you have any known allergies?
*
No known allergies
Medication allergies
Food allergies
Other
Are you currently taking any medications?
*
No
Yes
Please indicate if you have experienced any of the following symptoms recently:
*
Fever or chills
Cough or sore throat
Shortness of breath
Chest pain
Nausea or vomiting
None of the above
How would you rate your overall health today?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Have you had any major surgeries or hospitalizations in the past year?
*
No
Yes
Please list any questions or concerns you have about your upcoming procedure.
Submit Assessment
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