New jersey surgery center pre-operative interview form

New Jersey Surgery Center
NAME:________________________ M or F Height_____Weight______Age________
Procedure to be done_____________________________________________________________
Emergency contact person and number______________________________________________
Person who will provide your transportation home_____________________________________
Phone number where we can reach you between 7am – 3pm _____________________________
Please list allergies (with reactions) to food and/or medications or state NONE:
Do you have a latex allergy? Y/N If yes, please call us at 609-581-6230

: Have you ever been treated for any of the following:
___heart ___lungs ___liver ___kidney ___ulcers ___asthma ___arthritis
___blood pressure (high/low) ___diabetes (insulin Y/N) ___seizures ___stroke ___cancer ___thyroid ___bleeding disorder ___HIV/AIDS ___Hepatitis ___depression/anxiety ___GERD/reflux ___hiatal hernia Please describe all yes answers:____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Have you EVER been treated for sleep apnea or worn the CPAP machine at night? Y/N If yes, please call us at 609-581-6230. Please list all your daily medications including over the counter, vitamins and supplements: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Please list all surgery (s) you have had:_____________
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you or a family member had any complications from anesthesia? Y/N SOCIAL HISTORY:
Tobacco: No ___Yes ___ How much? ______ How many years? ____ Quit?(when)__________
Alcohol use: ___ heavy ___ moderate ___ social ___ occasional ___ none Do have any dentures/loose teeth/caps/bridges/braces? Permanent_____ Removable ____ Females: Last menstrual period__________ Pregnant? Y/N
for seven days before surgery (unless indicated otherwise by your physician):
Aspirin / Aspirin products Coumadin Plavix Aggrenox
STOP for three days before surgery (unless indicated otherwise by your physician):

The night before surgery:
If you take long acting insulin in the evening (NPH, Lantus etc.) only take ½ the dose!!!

The morning of surgery:
Do not take any insulin or medication for diabetes, we will check your sugar here.
Take your morning dose of blood pressure, heart, or thyroid medicine with a small sip of water.
Nothing to eat or drink after midnight. This includes candy, mints and gum.
No drinking alcohol, smoking or illicit drug use 24 hours prior to surgery.
Leave all jewelry and valuables at home.
Please refrain from wearing perfume/cologne the morning of surgery.
Bring any equipment as ordered.
Please email, fax or mail this form to:
New Jersey Surgery Center


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