HERNIA INSTITUTE OF PENNSYLVANIA
North Penn Hernia Institute
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PATIENT'S MEDICAL and PRE-OPERATIVE HISTORY
We appreciate your time spent providing us with the information below. It will help us in preparing you for your anesthesia care and surgery. An Anesthesiologist will review this information with you on the day of your surgery, examine you, and discuss your anesthesia care and options. Please CIRCLE any and all conditions
PAST or PRESENT, that apply to you and/or FILL IN the information requested.

PRINT NAME:_____________________________________ Height:___________ Weight:_________
Today's Date________ Age:____________
Surgical Procedure:________________________Surgeon: DR.____________Surgery Date________

CARDIAC (heart) VASCULAR:
PAST or PRESENT
Heart Attack* - Chest Pain/Pressure - Heart Murmur - Irregular Heart Beat - Palpitations - Heart Failure - Pacemaker/Defibrillator
Hypertension/High Blood Pressure
Can You climb 1 flight of stairs or walk 2 blocks without stopping due to chest pain or shortness of breath ? YES-NO
**PATIENTS WITH ANY SIGNIFICANT PAST CARDIAC or LUNG DISEASE HISTORY MUST OBTAIN AND PROVIDE
A COMPREHENSIVE EVALUATION FROM THEIR CARDIOLOGIST OR INTERNIST PRIOR TO SURGERY.
PLEASE DISCUSS THIS WITH US BEFORE SURGERY
RESPIRATORY:
(Lungs)
PAST or PRESENT
Asthma - COPD - Emphysema - Bronchitis - Pneumonia - Sleep Apnea - Cold in the past 4 weeks
Chronic Cough - Smoker (How much per day? _______packs)
RENAL(Kidney):
PAST or PRESENT
Dialysis - Kidney Failure - Kidney Stones - Prior Kidney Surgery
Other _____________________
HEPATIC
(Liver):
PAST or PRESENT
Hepatitis A, B or C - Cirrhosis Liver Failure
Alcohol consumed in an average week: ______drinks.
NEUROLOGICAL:
PAST or PRESENT
Strokes - Mini strokes/TIAs - Paralysis/Weakness - Multiple Sclerosis
Seizures - Parkinsonism - Alzheimer's Disease
ENDOCRINE:
PAST or PRESENT
Thyroid Problems - Diabetes Type I - Diabetes Type II
Other ___________________________
Date of Last Menstrual Period_____________
HEMATOLOGY :
PAST or PRESENT
Sickle Cell Disease - Von Willebrand's Disease - Hemophilia
Factor Deficiency - Bleeding Problems
MUSCULO -
SKELETAL :
PAST or PRESENT
Neck Problems - Lower Back Problems - Arthritis - TMJ
Arm Joint Stiffness R/L - Leg Joint Stiffness R/L
GASTRO-
INTESTINAL :
PAST or PRESENT
Ulcers - Hiatal Hernia - Heart Burn/Reflux - Ulcerative Colitis - Ileitis -Crohn's Disease - Bleeding
PSYCHIATRIC:
PAST or PRESENT
- Depression - Anxiety - Bipolar Disorder - Attention Deficit Disorder -Other______________








Please list ALL MEDICATIONS you take regularly (include herbal and natural medications and vitamins with doses:_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ALLERGYS?-LIST Any and All Medications or Substances to which you are Allergic:____________________________________________________________________

List ANY and ALL PREVIOUS SURGERY: Pleasealso include any bad reactions you may have had to anesthesia in the past:________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Any life-threatening reactions blood relatives have had to anesthesia:_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Any special concerns you have about anesthesia:_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

X__________________________________________________ DATE____/_____/_____
SIGNATURE (REQUIRED)

X_______________________________________PRINT___________________________
WITNESS (Preferred)

THANK YOU !!!!-An Anesthesiologist will review this information with you prior to your surgery at the North Penn Hernia Institute. An examination will also be performed at that time.DEPARTMENT of ANESTHESIA

IMPORTANT ANESTHESIA INFORMATION
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