The Surgery Center at Self Memorial Regional Hospital Greenwood

PreOP

Thank you for taking the time to complete this form. We appreciate you choosing Surgery Center of the Lakelands for your surgery. Please answer all questions so we may have a thorough medical history for our anesthesiologist. If you have any questions regarding your procedure please call (864) 725-7500. Please try to complete this form no less than 3 days before your procedure/surgery.

**Note** This form CAN NOT be completed on a mobile device or notebook. You must use a desktop or laptop. Sorry for any inconvenience.

Patient Information

Last Name First Name Middle Initial Date of Birth Patient Social Security Number Gender Martial Status Physical Street Address City State Zip Code Contact Telephone Number * Work Number Extension Cell Phone Number What is the best time of day we can contact you? Contact email address Is it ok to send information to this email address Place of Employment Occupation

The American Recovery and Reinvestment Act of 2009 requires that we gather additional information from you about your background. Thank you for answering the following three questions.

Race Ethnicity Primary Language

Designated driver/ Responsible adult for 24 hours

Please make certain they are available to remain in the facility for your entire visit. If your driver leaves the facility your procedure may be delayed or cancelled.

Name of designated driver Contact Telephone Number

Please be aware you are required to have a responsible adult available for 24 hours after surgery.

Please list an emergency contact person

First & Last Name Relationship of contact to patient Contact's Primary Telephone Number Contact's Secondary Telephone Number

Allergies

Do you have any allergies to medication, food, tape, etc? If so, please describe type and reaction.

Medical History

Height Weight

Are you completing the form for a child/minor (under the age of 18)?

Was the child premature at birth?

Gestational age

Respiratory

Have you had a flu shot during this flu season?

If other Respiratory/Breathing problems not listed above, please describe

Cardiovascular

When? Manufacturer of Pacemaker/Defibrillator

Are you currently under the care of a cardiologist?

If yes, please provide name of physician. If other Cardiovascular/Heart problems not listed above, please describe

Renal/ Endocrine

Last menstrual period If other renal/kidney problems not listed above, please describe

Neuro/Musculoskeletal

Exatension If other Neuro/Musculoskeletal problems not listed above, please describe

Gastrointestinal

If other Gastrointestinal/Stomach problems not listed above, please describe

Hematological

If other Hematological/Bleeding problems not listed above, please describe

Do you have a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) or Vancomycin- Resistant Enterococci (VRE)?

Are there any other medical issues that we need to be aware of? If so please describe below.

Social History

Any alcohol use?

Type How often? How much?

Previous tobacco use?

When did you last use tobacco?

Current tobacco use?

Type How much? How long have you been using tobacco products?

Any drug use?

Mobility Limitations

Medications

Please list your medications, supplements, herbals, etc. Please include dosages and how often you take them.

Medications

Are you currently taking any type of diet pill or have you taken any diet pill in the last 14 days?

Surgeries

Please list previous surgeries (dates are not necessary unless you have had a recent cardiac/ heart surgery)

Surgeries

Anesthesia History

Have you had any problems to anesthesia or being put to sleep?

Has anyone in the immediate family (blood relative) had problems to anesthesia or being put to sleep?

Primary Insurance Information

Insureds First Name Insureds Last Name Insured's Street Address City State Zip Code Insureds Employer Employer Street Address City State Zip Code Primary Insurance Name Insurance Group Number Insurance Identification Number Insured's Date of Birth Insureds Social Security Number Insurance Company Street Address City State Zip Code Insurance Companys Phone Number Insureds Relationship to Patient Primary Care Physician Name Primary Care Physicians Phone Number

Secondary Insurance

Secondary Insureds First Name Secondary Insureds Last Name Secondary Insured's Street Address City State Zip Code Insureds Employer Name Employer Street Address City State Zip Code Secondary Insurance Company Name Secondary Insurance Company Street Address City State Zip Code Secondary Insurance Group Number Secondary Insurance Identification Number Secondary Insured's Date of Birth Insureds Social Security Number Secondary Insurance Phone Number Insureds Relationship to Patient

Guarantor Info

Relationship to Patient Guarantor First Name Guarantor Last Name Primary Phone Number Secondary Phone Number Street Address City State Zip Code

Advance Directive/Living Will

Do you have an Advance Directive or a Living Will?

Thank you for taking the time in completing your preop assesment form. This will ensure we have accurate information to better serve you while you are at our facility. A preop nurse will be contacting you in the next couple of days to verify information, answer any questions you may have and give further instructions. Again, you are welcome to contact us at any time for further assistance (864) 725-7500 or toscnurse@myupdox.com

*Note: Please bring the following with you on the day of surgery: Insurance card, Photo ID, Living Will/Advanced Directive, Payment, and an extra change of clothing.

*Note: Please enter the patient's name below. (If you are completing this form for someone else please do not enter your name, remember to put patient's name below.)

Last Name * First Name * Middle Initial Date of Birth *