Presken Family Care - Pre-Surgical Exam

Ensuring a Successful Surgery

Please correct the errors described below.

Your First Name

Your Last Name

Your Date of Birth

COVID SCREENING QUESTIONS

In the past 7 days have you had any of the following: Check all that apply

Temperature greater than 99.0 degrees

Cough

Sore throat

Diarrhea

Trouble breathing

Exposure to someone with coronavirus symptoms or who has tested positive

Loss of smell

Loss of taste

None of the above

INFORMATION ABOUT YOUR SURGERY

Date of Your Surgery

Type/Name of Surgery

Reason for Surgery

Name of Surgeon/Group

EVALUATION QUESTIONS

Can you walk up one flight of stairs?

Yes No

Do you or anyone in your immediate family have a history or a clot in your legs or lungs?

Yes No

Do you have any history of complications from anesthesia?

Yes (describe below) No

Describe anesthesia complication here:

Are you currently having chest pain?

Yes No

Are you currently have shortness of breath?

Yes No

Do you have any false teeth?

Yes No

Do you have any history of blocked arteries of your heart?

Yes No

Do you have a history of rythm problems of your heart?

Yes No

Have you discussed with your surgeon a pain plan for after the surgery?

Yes No

Have you bought yourself a bag of prunes yet, in case you need narcotics for your pain?

Yes No

I understand that after submitting this form, a staff member will contact me to schedule my pre-surgical exam.

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