Pre-Op Questionnaire

Lakeside Dermatology

Patient Name

Age

DOB

Medication Allergies

Specific Allergies

Lidocaine

Epinephrine

Betadine

Iodine

Hibiclens

Chlorhexidine

Latex

History of Low Platelet Count or Platelet Disorder?

Yes No

History of bleeding disorder: Hemophilia, Factor V Leiden Mutation, etc.

Yes No

Medicines

Other

Implantable Electronic Devices

DBS

AICD

PACEMAKER

PAIN PUMP

SPINAL STIMULATOR

Artificial Joints

Yes No

If yes which joints and year replaced?

Artificial Heart ValveS

Yes No

If yes which Type of valve?

Mechanical Pig (Porcine) Cow (Bovine)

Year

Do you need to take Antibiotic when you go to the dentist?

Yes No

If yes, why?

History of HIV, AIDs, Hepatitis B, or C, or other infectious diseases?

Do you Smoke?

Yes No

If yes, # pack per day

# years smoking

Other tobacco?

For Office Use Only

Procedure Information

Date

Diagnosis

Location

Procedure

MOHS Excision Repair

Other Procedure

Pathology Number

Pre-Procedure Vitals

Blood Pressure

Heartrate

Consent Signed

Referring Physician

Nurse Completing Form

Medication Given

Time

Add another Medication/Time

Post-Procedure Vitals

Blood Pressure

Heart Rate

Your information will be encrypted.