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1. Name of your regular family doctor ______________________________________ Phone _____________________
OR ❏ I do not have a regular family doctor
2. Have you ever had any problems with blood pressure, previous heart disease, palpitations or angina? ❏ Yes ❏ No
If yes, please explain: _______________________________________________________________________________
3. Have you had an EKG in the past? ❏ Yes ❏ No If yes, where? when _________________________________________4. Have you had any ❏ breathing problems, ❏ asthma, ❏ hay fever, ❏ chronic bronchitis, ❏ emphysema or
5. Have you had any ❏ seizures, ❏ convulsions, ❏ migraine headaches, ❏ fainting spells or ❏ stroke?6. Have you had ❏ jaundice, ❏ hepatitis, ❏ liver disease or ❏ blood transfusion reactions?7. Do you have ❏ diabetes, ❏ hypoglycemia or ❏ thyroid problems?8. Do you have kidney problems? ❏ Yes ❏ No 9. Have you had ❏ a cold, ❏ sore throat, or ❏ flu in the last two weeks?10. Any recent exposure to tuberculosis? ❏ Yes ❏ No Any of the following symptoms: night sweats, cough with bloody sputum?11. Within the last two weeks have you had any exposure to chicken pox, mumps, measles (rubeola), German measles (rubella)?
12. Do you have any ❏ physical disabilities, ❏ back pain, ❏ arthritis or ❏ bursitis?13. Do you have sleep apnea? C-PAP? Sleeping disorders? Snoring? ❏ Yes ❏ No 14. Any other medical conditions? List: ____________________________________________________________________15. Do you have any implants? ❏ Yes ❏ No (Cardiac, Cosmetic, Orthopedic) List: _________________________________16. Have you ever had motion sickness?❏ Yes ❏ No 17. Do you smoke? ❏ Yes ❏ No How much/day? _________________________________________________________18. Do you drink alcoholic beverages? ❏ Yes ❏ No How much/week? _________________________________________19. Do you use recreational drugs? ❏ Yes ❏ No Please list __________________________________________________20. Do you have any ❏ loose teeth, ❏ dentures, ❏ permanent or removable bridges or ❏ front capped teeth?21. Do you wear contacts? ❏ Yes ❏ No 22. Do you have any difficulty opening your mouth? ❏ Yes ❏ No 23. Have you or any blood relative had an unusual reaction to anesthesia or malignant hyperthermia? ❏ Yes ❏ No 24. Are you allergic to anything? ❏ Yes ❏ No List: __________________________________________________________25. Do you have a latex allergy? ❏ Yes ❏ No 26. Do you currently take any medications ? ❏ Yes ❏ No27. Within the last year have you had cortisone or steroids? ❏ Yes ❏ No 28. Within the last two weeks have you taken ( Check ) ❏ a tranquilizer, ❏ diet pills or ❏ herbal medications? ❏ Yes ❏ No 29. Have you taken any medication today? ❏ Yes ❏ No List: __________________________________________________30. Do you use aspirin, ibuprophen (Motrin), Advil, Aleve, Naproxen or Anaprox? ❏ Yes ❏ No
Others ______________________________________ Last date taken? ______________________________________
31. Do you use blood thinners (Heparin, Lovenox, Coumadin, etc.)? ❏ Yes ❏ No Last date taken?____________________32. Do you have bleeding tendencies? ❏ Yes ❏ No 33. Could you be pregnant at this time? ❏ Yes ❏ No Date of last menstrual period: ________________________________34. Circle pain medications you have ever taken: | Tylenol | Percocet | Codeine | Aspirin | Darvocet | Vicodin | Other35. Height: _________________ Weight: ________________
(i.e. fever, nausea, vomiting, low blood pressure)
COMPLETED BY: ______________________________________________ RELATIONSHIP: __________________________________________ DATE: _____________________________________REVIEWED BY: PRE-OP RN: _______________________________OR R.N.: _____________________________________
450 North Roxbury Drive #520 | Beverly Hills | CA 90210 | 310-246-4628 | roxburysurgerycenter.com
Tobacco and Smoking Why is tobacco use by children and teens a problem? Nine out of ten tobacco users start smoking or using tobacco when they are under 18 years old. Children who start smoking at a young age are less likely to quit when they become adults. Smokers tend to die at an earlier age than non-smokers and are more likely to die from a smoking-related illness li
Multiple micronutrient supplementation increases the growth of Mexican infants1–4 Juan A Rivera, Teresita González-Cossío, Mario Flores, Minerva Romero, Marta Rivera, Martha M Téllez-Rojo,Jorge L Rosado, and Kenneth H Brown ABSTRACT many studies about the effect of individual micronutrients on Background: The role of single micronutrient deficiencies in the etiology of growth retard