Select Surgical Center at Kennedy Health Survey
We at the Select Surgical Center welcome you to participate in your surgical care. While all patients requiring
services of the Department of Anesthesiology will be seen personally prior to surgery, this Health Survey allows us to better identify those patients who may need specialized instruction. We depend on this survey along with the information provided by your surgeon to provide you with the appropriate care. Thank you for your help. Name:_________________________________ Date of Birth:____________ Height:______Weight: ______ Two phone numbers where we can reach you: 1.______________________ 2. _________________________ Can we leave a message if we do not reach you? NO YES May we speak to another person concerning your care? NO YES and name of person_______________________
Can you walk up a flight of stairs without
Getting short of breath Do you have diabetes
Do you have weakness of or paralysis Of your arms or legs
Do you have any implanted devices such As a pacemaker or defibrillator
Complete other side please
Have you ever had a problem with anesthesia other than vomiting
Has anyone in your family had a problem with anesthesia
Do you smoke presently, if yes, how much
Do you have any loose, false, capped or bonded teeth
Do you have any problems with your neck or opening your mouth
Do you take any of the following medications or herbal supplements for prostate, urinary or high blood pressure problems such as: Saw Palmentto, Flomax (tamsulosin), Uroxatrol (alsuzosin), Doxazosin, Hytrin (terazosin), prazosin or minipress
List ALL medications (including strengths and doses) you are taking –including herbal remedies:_________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ List all previous surgeries____________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ List all drug and food allergies_________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Latex Allergy: ____________________________________________________________________________________________________ Do you have anything specific you want to discuss with the anesthesiologist? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Signature________________________________________________ Date_______________________________________________
TO BE COMPLETED THE DAY OF SURGERY
I certify that I have had nothing to eat or drink since___________am/pm Patient Signature: __________________________________________ Date_________ Time __________ Name of Person who will driving me home ________________________________ Phone # _________________ Please print Parent/Guardian of children 18 years of age and under must remain in the facility until patient is discharged. Reviewed by: ________________________________________ Date_____________ Time: ___________
Natasha Menon (MA, MSW) El Dr. Michael Sherraden Washington University en St. Louis, EEUU. principal del Global Service Institute delsignificativas para el desarrollo de becasmentor del concepto de políticas contra lade servicio. Su investigación y sus interesespobreza basadas en los recursos propios. académicos incluyen el desarrollo social yDesde hace varias décadas public
by Catrin Lorch Expeditions in the Coral Reef “The ancient hordes are best imagined as floating islands. (.) under whose protection homo sapiens was able to develop into a being that outwardly avoids conflicts and inwardly luxuriates. “Im selben Boot”, Peter Sloterdijk (1995) The philosopher seeks new images to describe the polis ; unlike Plato (“the farmer from Athens”), S