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Pre-Admission Testing Prior to Surgery
Pre-Admission Testing Prior to Surgery
First Name
Last Name
Email Address
Address
Street Address
Address Line 2
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ZIP
Home Phone Number
Cell Phone Number
Work Phone Number
Age
Date of Birth
Height
Weight
Date Scheduled For Surgery
Doctor
- Select -
Richard H. Alfred, M.D.
R. Maxwell Alley, M.D.
Kaushik Bagchi, M.D.
Kelley E. Banagan, M.D.
Robert A. Cheney, M.D.
Ernest N. Chisena, M.D.
Keegan P. Cole, M.D.
Cory Czajka, M.D.
Shankar P. Das, M.D.
Matthew R. DiCaprio, M.D.
John A. DiPreta, M.D.
Michael A. Flaherty, M.D.
Andrew C. Gerdeman, M.D.
Alexander R. Harbin, M.D.
Anjum Iqbal, M.D.
Hamish A. Kerr, M.D.
Thomas J. Kryzak, Jr., M.D.
Jordan M. Lisella, M.D.
Abigail Mantica, M.D.
Patrick G. Marinello, M.D.
Colleen M. Moreland, D.O.
Andrew S. Morse, M.D.
Michael T. Mulligan, M.D.
Robert E. O’Leary, M.D.
Dionisio Ortiz, III, M.D.
Daniel T. Phelan, M.D.
David E. Quinn, M.D.
Alexander R. Riccio, M.D.
Jared T. Roberts, M.D.
Andrew Rosenbaum, M.D.
James M. Schneider, M.D.
Kimberley Schuller, D.O.
Todd Shatynski, M.D.
Natalie V. Singer, M.D.
Matthew W. Tetreault, M.D.
Richard L. Uhl, M.D.
Richard R. Whipple, M.D.
George Zanaros, M.D.
Joseph P. Zimmerman, M.D.
Primary Care Physician
What are you having done?
What side?
Please list any medications you are taking orally (including diet pills, prescriptions, over-the-counter medications, vitamins, and herbal remedies)
Allergies
Yes
No
Please list all allergies
Latex Allergy
Yes
No
High Blood Pressure
Yes
No
Chest Pain
Yes
No
Congestive Heart Failure
Yes
No
Mitral Valve Disease
Yes
No
Prior Heart Attack
Yes
No
Heart Attack Date
Other Cardiovascular Disease
Yes
No
If yes, please explain
Asthma
Yes
No
Emphysema
Yes
No
Shortness of Breath
Yes
No
Sleep Apnea
Yes
No
Tuberculosis
Yes
No
Other Respiratory Disease
Yes
No
If yes, please explain
Anxiety / Depression / Mental Illness
Yes
No
Hearing Deficit
Yes
No
Numbness or Tingling
Yes
No
Seizure Disorder
Yes
No
TIA / Stroke History
Yes
No
Residual?
Yes
No
Other Central Nervous System Disease
Yes
No
If yes, please explain
Hepatitis / Jaundice History
Yes
No
Heartburn / Gastric Reflux
Yes
No
Diabetes
Type I
Type II
No
Other GI Disease
Yes
No
If yes, please explain
Cancer
Yes
No
Cancer Type
Thyroid Disease
Yes
No
Kidney Disease
Yes
No
Arthritis
Yes
No
Arthritis Neck Involvement?
Yes
No
Sickle Cell Disease
Yes
No
Bleeding Disorders
Yes
No
Bleeding Disorder Type
Do you have a living will or healthcare proxy?
Yes
No
Pregnant
Yes
No
Date of last period
Other Medical Conditions
Yes
No
If yes, please explain
Do you have any open cuts or wounds?
Yes
No
Family / Self History of Malignant Hyperthermia
Yes
No
Motion Sickness
Yes
No
Smoker
Yes
No
Packs Per Day
Alcohol Consumption
Yes
No
Number of Alcoholic Drinks / Week
Recreational Drug Use
Yes
No
Drug Type
Previous Surgeries
Yes
No
If yes, please list below
Difficulties With Anesthesia
Yes
No
If yes, please explain
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Doctors
Richard H. Alfred, M.D.
R. Maxwell Alley, M.D.
Kaushik Bagchi, M.D.
Kelley E. Banagan, M.D.
Robert A. Cheney, M.D.
Ernest N. Chisena, M.D.
Keegan P. Cole, M.D.
Cory Czajka, M.D.
Shankar P. Das, M.D.
Matthew R. DiCaprio, M.D.
John A. DiPreta, M.D.
Michael A. Flaherty, M.D.
Andrew C. Gerdeman, M.D.
Alexander R. Harbin, M.D.
Anjum Iqbal, M.D.
Hamish A. Kerr, M.D.
Thomas J. Kryzak, Jr., M.D.
Jordan M. Lisella, M.D.
Abigail Mantica, M.D.
Patrick G. Marinello, M.D.
Colleen Moreland, D.O.
Andrew S. Morse, M.D.
Michael T. Mulligan, M.D.
Robert E. O’Leary, M.D.
Dionisio Ortiz, III, M.D.
Daniel T. Phelan, M.D.
David E. Quinn, M.D.
Alexander R. Riccio, M.D.
Jared T. Roberts, M.D.
Andrew Rosenbaum, M.D.
James M. Schneider, M.D.
Kimberley Schuller, D.O.
Todd Shatynski, M.D.
Natalie V. Singer, M.D.
Matthew W. Tetreault, M.D.
Richard L. Uhl, M.D.
Richard R. Whipple, M.D.
George Zanaros, M.D.
Joseph P. Zimmerman, M.D.
Specialties
Ankle
Back
Elbow
Foot
General Orthopaedics
Hand
Hip
Knee
Neck
Orthopaedic Oncology
Pediatric Orthopaedics
Physical Medicine & Rehabilitation
Shoulder
Spine
Sports Medicine
Total Joint Replacement & Revision
Trauma
Wrist
Services
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Durable Medical Equipment (DME), Casting & Splinting
Magnetic Resonance Imaging (MRI)
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