Who are you scheduled to see?
- Select One - C Emory Johnson Jr MD Gregory Lee MD Guy Foulkes MD John Chrabuszcz MD John Sapp MD Kimberly Gilbert MD Richard Thomas MD Robert Blackwell MD Robert Thornsberry MD Waldo Floyd III MD William Dasher III MD Winston Jeshuran MD
What is your First name?

What is your Last name?

What is your date of birth?
/ /
Do you take antibiotics before going to the dentist or having surgery?
Yes   No
For what type of problem?

Have you been diagnosed with a Latex allergy?
Yes   No
What kind of reaction do you have?

Do you have an allergic reaction to any medications?
Yes   No
Please list them below.

Do you have an allergic reaction to any food?
Yes   No
Please list them below.

Have you undergone prior surgeries or procedures that required anesthesia?
Yes   No
Please list each surgery or procedure below.

Do you take any prescription or over the counter (OTC) medications?
Yes   No
Please list the medication, strength and times per day.

Do you have any history of Hepatitis, HIV, or any other Infectious Disease?
Yes   No
Please provide more detail.

Do you use Oxygen?
Yes   No
*Please bring a Full Tank with you on the date of your surgery.
Are you currently taking any blood thinners? (Prescription or OTC)
Yes   No
Please select which ones below.
Coumadin
Plavix
Aggrinox
Persantine
ASA
Motrin
Non Rx
Other(s)
Have you had any recent medical problems or illness?
Yes   No
Please give more details.

Do you use tobacco products?
Yes   No
What type and how much per day?

Do you drink alcohol?
Yes   No
How often and how much?

Have you or any member of your family ever had a high temperature as you were being put to sleep (malignant hyperthermia)?
Yes   No

Reminders:

• Please bring all prescriptions in orginal bottles on the day of your preoperative appointment.