GEORGIA UROLOGY AMBULATORY SURGERY CENTER 2685 MILSCOTT DRIVE, DECATUR, GA 30033 TELEPHONE 404-292-7333

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GEORGIA UROLOGY AMBULATORY SURGERY CENTER 2685 MILSCOTT DRIVE, DECATUR, GA 30033 TELEPHONE 404-292-7333 PLEASE PRINT, COMPLETE AND RETURN THE FOUR PAGE PRE-OPERATIVE HEALTH QUESTIONNAIRE WITHIN 5 DAYS OF RECEIVING YOUR DATE FOR SURGERY. YOU CAN FAX TO 404-292-3451 OR MAIL TO THE SURGERY CENTER AT THE ABOVE ADDRESS. IF YOU WISH TO SCAN AND EMAIL, PLEASE CALL THE SURGERY CENTER FOR INSTRUCTIONS. NAME DATE OF BIRTH AGE HEIGHT FEET INCHES WEIGHT LBS. Home phone Cell phone Day phone E-mail Pharmacy name Pharmacy phone Is English your primary language? 1 Yes 1 No If not, your primary language is: Primary care doctor s name Date last seen Phone Specialty physicians Name Specialty Date last seen Phone Name Specialty Date last seen Phone ALLERGIES: 1 I AM NOT ALLERGIC TO ANYTHING THAT I KNOW OF PLEASE LIST ALL ALLERGIES 1 5 2 6 3 7 4 8 Initial and date here, please

MEDICATIONS: PLEASE LIST (WITH DOSAGE AND FREQUENCY) ALL PRESCRIPTION, NON-PRESCRIPTION, OVER-THE-COUNTER MEDICATIONS AND HERBAL PREPARATIONS YOU TAKE 1 CHECK BOXES ARE FOR ASC INTERNAL USE 1 I TAKE NO MEDICATIONS For ASC internal use: Instruct patient to take medications checked on the AM of surgery with a sip of water. Anesthesiologist Signature Date PLEASE LIST ALL SURGERIES YOU HAVE HAD AND THE DATE(S) OPERATION NAME 1 DATE 2 3 4

PLEASE TELL US ABOUT YOUR HEALTH. PLEASE READ EACH SECTION CAREFULLY AND CHECK ALL THAT APPLY. 1. Do you have or have had any breathing issues? 1 Asthma 1 Emphysema 1 Chronic lung disease 1 Use oxygen at home 1 Sleep apnea 1 Mild 1 Moderate 1 Severe 1 Sleep study When? Where? 1 C-PAP 1 B-PAP 1 Loud snoring 1 Awaken from sleep with a choking sensation 1 Frequently wake up from sleep 1 Frequent daytime sleepiness or fatigue in spite of adequate sleep 1 Fall asleep easily in a non-stimulating environment (watching TV, reading, riding in or driving a car) in spite of adequate sleep What is your neck size? inches 2. Do you have or have had any of the following heart or circulatory issues? 1 High blood pressure 1 Heart attack 1 Irregular heart beat 1 Heart bypass surgery 1 Chest pain 1 Heart artery stent(s) 1 Heart murmur 1 Angioplasty 1 Heart valve replacement 1 Other blood vessel surgery 1 Heart artery blockage 1 Heart failure 3. Do you have or have had any of the following? 1 Diabetes 1 Thyroid problems 1 Stroke 1 Seizure disorder 1 Difficulty swallowing 1 Difficulty breathing deeply 1 Impaired mobility 1 Bleeding disorder 1 Gastric reflux disorder 1 Kidney disorder 1 Liver disorder

1 Implant(s) of any kind 1 Lens 1 Shunt 1 Heart valve 1 Joint 1 Pacemaker 1 Defibrillator 1 Pins, screws, rods or plates 1 Open areas on skin or draining sores 1 Exposure to or current active infection 1 Tuberculosis 1 Hepatitis 1 Staph 1 Other 1 Broken bone in face or jaw 1 Jaw or nose surgery 1 Blood relative who ever had difficulty with anesthesia Who? What happened? Initial and date here, please

4. Please tell us something about your lifestyle habits. 1 I exercise regularly. I exercise approximately hours a week. What kinds of exercise do you do? 1 I don t exercise regularly. 1 I smoke cigarettes. How many packs per day? For how many years? 1 I drink some alcohol. What kind? How much and how often? 1 I use some recreational substances. What kind? How much and how often? 5. Have you had any of the following tests? 1 Cardiogram (EKG) in the last 6months? Where? 1 Chest X-ray in the last 6 months? Where? 1 Blood tests in the last month? Where? If you have not had a cardiogram (EKG) in the last 6 months, when did you last have a cardiogram (EKG)? Where? 6. Women: 1 I am able to become pregnant. Date of last menstrual period: 1 I have had a pregnancy test within the last 2 weeks. 1 I have had a tubal ligation. 1 I have had a hysterectomy. 1 I am menopausal. Date of last menstrual period: SIGN HERE, PLEASE DATE OF COMPLETION For ASC internal use only: BMI 1 Cleared for anesthesia 1 Items needed for clearance: Anesthesiologist signature Date

THANK YOU VERY MUCH FOR YOUR RESPONSES. A NURSE FROM THE SURGERY CENTER WILL CALL YOU TO CONFIRM THAT YOUR COMPLETED PREOPERATIVE QUESTIONNAIREWAS RECEIVED. SHE MAY ASK YOU TO CLARIFY SOME OF YOUR RESPONSES. IF YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE CALL THE GEORGIA UROLOGY ABULATORY SURGERY CENTER AT 404-292-7333 AND ASK TO SPEAK TO ONE OF THE PRE-OP NURSES. THE GEORGIA UROLOGY AMBULATORY SURGERY CENTER IS HERE TO SERVE YOU. WE THANK YOU FOR TAKING THE TIME TO ASSIST IN PREPARING FOR YOUR UPCOMING SURGERY.

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