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Contact Information
List Your Allergies & Reactions


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

Anesthesia Background | Check All That Apply
Previous Surgeries
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
IMPORTANT: Please bring CPAP to your procedure
Other Health History
For Colonoscopy Patients Only:
Check All that Apply:
For Nursing Home Patients ONLY:
Please send EMR day of surgery/procedure to show what the patient has taken for medications that morning.