Pre-Procedure Online History

Procedure Information


Personal Information

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Who will be your designated driver/responsible person to come with you?
This person will need to remain in the lobby during the entire procedure.

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Medical Information

What medications do you take?


+ Add Another Medication


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Per day:

Per week:

Per month:

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Use of non-prescribed drugs, especially cocaine, will affect medication used during surgery.

Angina
Chest Pain
Heart Attack
Palpitations
Arrhythmia
Congestive Heart Failure

Enlarged Heart
Rheumatic Fever
Heart Murmur
Mitral Valve Prolapse
High Blood Pressure

Sleep Apnea

Yes No

Please bring your CPAP machine with you the day of your procedure.

TB (Tuberculosis)
COPD (Chronic Obstructive Pulmonary Disease)
Pneumonia
Asthma
Bronchitis
Emphysema

Diabetes



Thyroid Problems
Endocrine Problems

Hepatitis
Cirrhosis
Yellow Jaundice

AIDS (Acquired Immune Deficiency Syndrome)
HIV (Human Immunodeficiency Virus)
Sickle Cell Disease

Blood Problems
Anemia
Unusual Bleeding or Bruising Tendency
Low Platelets

Tumor
Cancer
Leukemia

Seizures
Epilepsy
Stroke

Cerebral Palsy
Muscular Dystrophy
Multiple Sclerosis
Myasthenia Gravis

Arthritis
Joint Disease
Do you have problems opening your mouth or moving your neck?

Heartburn
Acid Reflux
Hiatal Hernia

Kidney Problems
Do you have black colored urine?

Have you ever had a bad reaction to Barbiturates?

Glaucoma

Could you be pregnant?

Capped Teeth
Loose Teeth
Chipped Teeth
Dentures

Do you suffer from any medical problems not already listed?

Redness
Rashes
Lesions
Open Wound

Do you take any type of Anticoagulant (blood thinner)?

Examples: Aspirin / Coumadin / Plavix / Effient

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Legal Information

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Bring a copy of the Living Will with you on the day of your procedure.


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Bring a copy of the Power of Attorney with you on the day of your procedure.


If you have questions about your procedure please contact your physician. If you have problems or questions about filling out this form you can email your question to patweb@chgroup.org and someone will respond to your question within 24 hours on business days. We can be reached by phone at 256-768-8886.

Disclaimer: If you elect to electronically submit a completed Pre-registration Form or any other information to ECM/Shoals Hospital through this site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold ECM/Shoals Hospital and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to ECM/Shoals Hospital by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and ECM/Shoals Hospital, its affiliates, or any of the physicians on its staff, to which any privilege may attach.