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Surgery Forms

Pre-Operative Questionnaire

Pre-Op Form | Anesthesia Procedure

This form will take approximately 10-15 minutes to complete. It is not complete until you hit send and receive a confirmation email. 

Contact Information
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List Your Allergies & Reactions
Medications

*Stop Coumadin and Herbal Supplements 5 days prior to the procedure.
Stop Aspirin and Plavix 7 days prior to the procedure.

IMPORTANT: If your physician is with Saunders Medical Center Family Care Clinic we will obtain this list for you. If not, note your medications below.
Anesthesia
Anesthesia Background | Check All That Apply
Previous Surgeries
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Current Health Information
Women Only: Date of last menstrual period
I have and use: (Check all that apply)
Your Health History
Heart Health
Please check all that apply to you and note comments below on each section.
Steroid, Alcohol or Illegal Drug Use
Kidney Health History
Seizures | Mental Health History
Lung Health History
Respiratory
CPAP Settings
IMPORTANT: Please bring CPAP to your procedure
Other Health History
Other Health History
For Colonoscopy Patients Only:
Check All that Apply:
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