EmailMe Form - Taylor Station Patient History Form

Taylor Station Patient History Form - 614-751-4466

Please include as much information as possible.

1. Please Print Your Full Name: *

First Last

2. If you Prefer to go by another name Please specify:

First Last

3. Birthdate: *

MM / DD / YYYY

4. When is your surgery scheduled? *

MM / DD / YYYY

5. What is your race? *

6. What is your Ethnicity? *

7. Please Note all Allergies and reactions (medications, latex, adhesive and food allergies. N/A if none). *

8. Please provide the best number for us to contact you *

### - ### - ####

9. Do you have any Advanced Directives, Living Will, or Healthcare POA? Please Specify if Yes *

Yes

No

9a. Please Specific Advance Directives, Living Will, or Healthcare POA: *

10. Do you feel safe at home? *

Yes

No

11. Do you have any special / educational needs? If yes please explain *

Yes

No

11a. Please Explain any special / educational needs: *

12. Is your preferred Language English? If no please provide language & do you need an interpreter? *

Yes

No

12a. Please provide language & do you need an interpreter? *

13. Who is coming with you the day of surgery? Please tell us their name and relationship to you *

First Last

13a. Relationship: *

14. Do you have any Privacy concerns? *

Yes

No

14a. Please explain Privacy Concerns: *

15. Prior Fall history and/or unsteady when walking? *

Yes

No

16. Have you been ill or spent the night in the hospital in the last 3 months? If yes please explain: *

Yes

No

16a. Please explain: *

17. Have you had any recent infections? *

Yes

No

17a. If Yes, Please Explain: *

18. Have you or any immediate family members traveled outside of the U.S. in the last 6 Months? *

Yes

No

18a. If Yes, Please Explain: *

19. Do you feel well enough to have your scheduled surgery / procedure? If no explain *

Yes

No

19a. Please explain: *

20. What is your height?: *

21. What is your weight?: *

21a. BMI: *

Please insert BMI from calculator ->

22. Primary Care/Family Physician? *

First Last

22a. Primary Care phone number: *

### - ### - ####

23. Have you had any recent Laboratory test or EKG's done?: *

Yes

No

23a. If Yes, When and Where?: *

24. How do you rate your nutrition?: *

25. Who is the physician doing your procedure?: *

25a. What surgery / Procedure are you having?: *

26. Why are we doing this procedure?: *

Medication 1:

Dose:

Frequency:

Reason for taking:

Medication 2:

Dose:

Frequency:

Reason for taking:

Medication 3:

Dose:

Frequency:

Reason for taking:

Medication 4:

Dose:

Frequency:

Reason for taking:

Additional Medications?

Yes

No

Medication 5:

Dose:

Frequency:

Reason for taking:

Medication 6:

Dose:

Frequency:

Reason for taking:

Medication 7:

Dose:

Frequency:

Reason for taking:

Medication 8:

Dose:

Frequency:

Reason for taking:

Medication 9:

Dose:

Frequency:

Reason for taking:

Medication 10:

Dose:

Frequency:

Reason for taking:

Additional Medications:

Medication/Dose/Frequency/Reason for taking

27. Are you currently experiencing any pain?: *

Please rate your pain on a scale of 1-10 (0 being no pain and 10 being worst pain)

28. What is an acceptable Pain range using a scale of 0-10?: *

(0 being no pain and 10 being worst pain)

29. Have you ever had anesthesia? *

Yes

No

30. Have you ever had any problems with anesthesia? *

Yes

No

Ex. Post op nausea vomiting, Malignant hyperthermia, or been told you have a difficult airway.

30a. If Yes, Please Explain: *

31. Have any family members had any issues with anesthesia, such as Malignant Hyperthermia? *

Yes

No

31a. If Yes, Please Explain: *

Respiratory

32. Do you snore loudly? (Louder than talking or loud enough to be heard through doors)? *

Yes

No

33. Do you often feel tired, fatigued, or sleepy during the daytime? *

Yes

No

34. Has anyone ever observed you stop breathing during your sleep? *

Yes

No

35. Sleep Apnea / C-PAP? *

Yes

No

35a. If Yes, what CPAP setting: *

35b. How often do you use CPAP? *

Always

Sometimes

Never

NOTICE: Please bring CPAP machine and supplies with you to the surgery center.

36. Respiratory, check all that apply: *

36a. If other please explain: *

37. Respiratory - Any changes in the last 3-6 months? *

Yes

No

37a. If yes please specify: *

Neurovascular / Muscular

38. Stroke / TIA? *

Yes

No

38a. If Yes, When and Deficits: *

39. Blood Clot? *

Yes

No

39a. If Yes, Where was the blood clot? *

40. Artificial joint(s)? *

Yes

No

40a. If yes please explain including Date and Which Joint: *

41. Please select all that apply: *

42. Any changes in the last 3-6 months? *

Yes

No

42a. If yes please explain: *

Gastrointestinal

43. Please select all that apply: *

44. Any changes in the last 3-6 months? *

Yes

No

44a. If yes please explain: *

Cardiovascular

45. Chest Pain / Angina? *

Yes

No

45a. If yes please explain and when was last episode? *

46. Heart Attack / MI / Blockages in Heart? *

Yes

No

46a. Please tell us when: *

MM / DD / YYYY

47. Heart Cath? *

Yes

No

47a. If yes when? *

48. Stress Test? *

Yes

No

48a. If yes please explain: *

49. Echo Test? *

Yes

No

49a. If yes please explain: *

50. Open heart surgery? *

Yes

No

50a. If yes explain? *

51. Irregular heart rate? *

Yes

No

51a. If yes explain? *

52. Pacemaker / ICD? *

Yes

No

52a. Date implanted and manufacturer: *

53. Please select all that apply: *

53a. Please explain other heart problems: *

54. Circulation problems? *

Yes

No

55. Do you have a cardiologist? *

Yes

No

55a. Please provide their name: *

First Last

55b. Please provide their phone number: *

### - ### - ####

56. Any changes in the last 3-6 months? *

Yes

No

56a. Please explain: *

Metabolic / Blood

57. Please select all that apply: *

58. History of Diabetes? *

Yes

No

58a. If Yes: *

Diet Controlled

Pills

Insulin

59. Cancer specific type of disease? *

Yes

No

59a. Please explain when?: *

60. Bleeding disorder? *

Yes

No

60a. Please explain here: *

61. Dialysis? *

Yes

No

61a. If Yes, when and where was last dialysis treatment?: *

62. Any changes in the last 3-6 months? *

Yes

No

62a. If yes please explain: *

Psycho-Social

63. Alcohol use? *

Yes

No

63a. If Yes, How much? How often? *

64. Tobacco use? *

Yes

No

64a. If Yes, How much? *

65. Psychiatric disorder? *

Yes

No

65a. If yes, please explain: *

66. STD? *

Yes

No

66a. If yes, please explain: *

67. Illegal Drug Use? *

Yes

No

67a. If yes, please explain: *

68. Any changes in the last 3-6 months? *

Yes

No

68a. If yes, please explain: *

Reproductive

69. Please select your sex: *

Female

Male

69a. Last menstrual cycle?:

MM / DD / YYYY

70. Have you received the flu vaccine?: *

Yes

No

70a. If yes, when?: *

MM / DD / YYYY

71. Have you received pneumococcal vaccine?: *

Yes

No

77a. If yes, when?: *

MM / DD / YYYY

72. Have you received shingles vaccine?: *

Yes

No

72a. If yes, when?: *

MM / DD / YYYY

73. Have you any existing implants in your body?: *

Yes

No

73a. If yes, please explain: *

74. Please list all previous surgeries: *

75. Please list any family history: *

Instructions: Please read instructions for surgery or upper endoscopy and/or colonoscopy

Bring your insurance card and driver's license.

If you have an advance directive please bring with you to the Center.

Please wear your glasses but no contacts.

Wear comfortable clothing, if you are having Breast or Shoulder surgery wear a button up shirt.

DO NOT bring jewelry, money (except for your payment due day of procedure) or other valuables on the day of procedure, otherwise we will give it to your visitor to hold during your procedure.

All metal or piercings on your body must be removed prior to surgery.

Pre- procedure bathing/oral hygiene is essential for surgery. Once you bathe with soap do not put on any lotions, powders or hairsprays for head, neck, facial, upper back or upper extremity surgery.

You MUST have an adult bring you and take you home from surgery.

You MUST have someone stay with you that evening after surgery.

No children under the age of 12 permitted in patient care area.

Do not eat and drink according to the Center's directions once they call you, or your Physicians directions.

Do not consume any mints, gum alcohol, or any tobacco products 12 hours prior to surgery.

Follow your doctor's instructions, If you have any questions call the office.

If you are having Orthopedic Surgery bring any assistive devices you have at home, otherwise we can provide and the company will bill you for the product.

Taylor Station requires 2 Business Day notification for cancellations.

Taylor Station Surgical Center, LTD

Transportation/Transfer and Responsible Adult Agreement

Taylor Station Surgical Center, LTD (“Taylor Station”) requires each patient having
a procedure involving anesthesia to be discharged in the company of a
responsible adult and for this person to serve as my driver/caregiver to transport
patients home after the procedure.

I acknowledge that I have a responsible adult for purposes of discharge and that
this person will serve as my driver/caregiver to transport me and stay with me
after returning home from my procedure. I acknowledge that having such a
person is required in order to have my procedure at Taylor Station. If no
responsible adult is available at discharge for these purposes, I acknowledge that I
will be transferred to the hospital to ensure my safety and Taylor Station will not
be financially responsible for the cost of the transfer or hospital stay. I also
understand public transportation such as a bus, Uber, Lyft or taxi is prohibited
unless I am accompanied by my adult driver/caregiver.
By signing below, in consideration for the procedure I have requested to be
performed, I agree to accept the financial liabilities associated with any hospital
stay in the event I do not have a responsible adult available at discharge and to
transport me home at my time of discharge. To the fullest extent permitted by
applicable law, I hereby release, forever discharge, and covenant not to sue Taylor
Station, its affiliated companies, and their respective employees, members,
officers, directors, managers, agents, and assigns, of and from all known or
unknown claims or causes of action for liability, personal injury, death, pain and
suffering, losses, lost wages, back pay, front pay, lost benefits, cost and expenses
(including attorney's fees and costs actually incurred), and any other claims or
damages of whatsoever kind or nature, either in law or in equity, arising from,
connected with or in any way related to my failure to have a responsible adult
driver/caregiver transport me home and stay with me following my discharge
from Taylor Station.

I understand all instructions noted above: *

Yes

No

Patient Name: *

First Last

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