Please list all prior surgeries: Tape Allergies? I agree to a blood transfusion in an Yes No emergency situation Latex Allergies? Do you currently have an abdominal / incisional hernia? Yes No Yes No Do take any NSAIDS such as Ibuprofen, Motrin, Aleve, Do you take any blood thinning medications such as Celebrex or Naprosyn? Coumadin, warfarin, aspirin, or Plavix? Yes No Yes No I use tobacco(including smoke, dip, chew, nicotine gum/patches): How Often: How Many Years: When Did You Quit: I drink alcohol: How Often: How Many Years: When Did You Quit: I use recreational Drugs: How Often: How Many Years: When Did You Quit: I use Birth Control: Pills Condoms Tubal Ligation Other: Do you have or use any of the following: HEARTBURN/REFLUX HYPERTENSION (HIGH BLOOD PRESSURE) INDIGESTION / DYSPEPSIA DIABETES MELLITUS PROBLEMS SWALLOWING / EXCESSIVE CLEARING OF THROAT SLEEP APNEA - CPAP or BI PAP ACID METALLIC IN MOUTH / SOUR STOMACH HEART DISEASE COUGHING / HOARSENESS LUNG DISEASE (COPD/Emphysema) - Home Oxygen VOMITING OR REGURGITATION WHEN DOWN PULMONARY EMBOLISM FOOD GETS STUCK IN THROAT SHORTNESS BREATH AND EXERCISE INTOLERANCE DUE TO GASSINESS / BLOATING OBESITY STOMACH ASTHMA COLITIS BLOOD CLOTS DISEASE/ ULCERATIVE COLITIS BLOOD TRANSFUSION HYPERCHOLESTEROLEMIA (ELEVATED CHOLESTEROL) LIVER DISEASE ( Hepatitis B, Hepatitis C ) HYPERTRIGLYCERIDEMIA (ELEVATED TRIGLYCERIDES) HIV/ AIDS URINARY STRESS INCONTINENCE (WEAK BLADDER) KIDNEY DISEASE - Dialysis CHRONIC BACK AND JOINT PAIN THYROID PROBLEMS ARTHRITIS LUPUS MIGRAINE HEADACHES EDEMA (LEG SWELLING) DEPRESSION / BIPOLAR DISORDER/ANXIETY FREQUENT PREDNISONE USE FAMILY HISTORY: OBESITY, DIABETES, HYPERTENSION, HEART DISEASE, CANCER Last name: D.O.B.: Medication Allergies? Yes No If Yes, please list:
Please list all prior surgeries: I agree to a blood transfusion in an emergency situation Tape Allergies? Yes No Latex Allergies? Yes No Do take any NSAIDS such as Ibuprofen, Motrin, Aleve, Celebrex or Naprosyn? Yes No Do you currently have an abdominal / incisional hernia? Yes No Do you take any blood thinning medications such as Coumadin, warfarin, aspirin, or Plavix? Yes No I use tobacco(including smoke, dip, chew, nicotine gum/patches): How Often: How Many Years: When Did You Quit: I drink alcohol: How Often: How Many Years: When Did You Quit: I use recreational Drugs: How Often: How Many Years: When Did You Quit: I use Birth Control: Pills Condoms Tubal Ligation Other: Do you have or use any of the following: HYPERTENSION (HIGH BLOOD PRESSURE) DIABETES MELLITUS SLEEP APNEA - CPAP or BI PAP HEART DISEASE LUNG DISEASE (COPD/Emphysema) - Home Oxygen PULMONARY EMBOLISM SHORTNESS BREATH AND EXERCISE INTOLERANCE DUE TO OBESITY ASTHMA BLOOD CLOTS BLOOD TRANSFUSION LIVER DISEASE ( Hepatitis B, Hepatitis C ) HIV/ AIDS KIDNEY DISEASE - Dialysis THYROID PROBLEMS LUPUS HEARTBURN/REFLUX INDIGESTION / DYSPEPSIA PROBLEMS SWALLOWING / EXCESSIVE CLEARING OF THROAT ACID METALLIC IN MOUTH / SOUR STOMACH COUGHING / HOARSENESS VOMITING OR REGURGITATION WHEN DOWN FOOD GETS STUCK IN THROAT GASSINESS / BLOATING STOMACH COLITIS DISEASE/ ULCERATIVE COLITIS HYPERCHOLESTEROLEMIA (ELEVATED CHOLESTEROL) HYPERTRIGLYCERIDEMIA (ELEVATED TRIGLYCERIDES) URINARY STRESS INCONTINENCE (WEAK BLADDER) CHRONIC BACK AND JOINT PAIN ARTHRITIS MIGRAINE HEADACHES EDEMA (LEG SWELLING) DEPRESSION / BIPOLAR DISORDER/ANXIETY FREQUENT PREDNISONE USE FAMILY HISTORY: OBESITY, DIABETES, HYPERTENSION, HEART DISEASE, CANCER Last name: D.O.B.: Medication Allergies? Yes No If Yes, please list: