Sarasota Physicians Please print and fi ll out this form carefully and completely. Take it to Surgical Center the Sarasota Ph ysicians Surgical Center on the day of surgery. Procedure: ______________________________________________ Height: _____________ Weight: ______________ Are you allergic to latex? ( Please circle and notify the nurse on admission ) Yes No List Other Allergies: List ALL Previous Surgeries: _______________________________________________ _____________________________________________________
__________________________________________ _ _______________________________________________
__________________________________________ _ _______________________________________________ __________________________________________ _ _______________________________________________ Do you take any blood thinners? Coumadin List Below ALL your other medications including ov er-the-counter, vitamins, & herbal supplements. Name of Medication How taken How often Reason for taking Last taken? Leave this this medication column blank Check this box if you do not take any medications Answer YES or NO for EACH DISEASE YES NO Substance Use YES NO Anesthesia Problems YES NO Cardiovascular Disease YES NO Pulmonary Disease Smoking History: NO Other: YES _____ Packs / Per day
Valve Disease/Heart Murmur Other: _____________________
_____ Years YES NO Teeth QUIT WHEN? __________
Shortness of Breath When YES NO Endocrine Disease Comments YES NO Neurological Disease
Seizures/Epilepsy YES NO Infectious Diseases _______________________________________________ _______________________________________________ _______________________________________________
Other: ___________________ YES NO GI Disease Reviewed by Doctor _________ Reviewed by CRNA _________ YES NO Blood Disease Reviewed by Doctor _________ Reviewed by CRNA _________ YES NO Kidney Disease YES NO Pediatrics
Revised 6/8/09 SPSC Pre-Anesthetic Evaluation Form
ORDONNANCE COLLECTIVE : Initier les mesures thérapeutiques auprès de la clientèle hémodialysée porteuse du Staphylococcus aureus sensible à l’oxacilline (SASO) ou résistant à la méthicilline (SARM) Sommaire : Date de mise en vigueur: Février 2011 Débuter le traitement de décolonisation par l’application intra nasale de Mupirocine (BactrobanMD) ou d’a
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