This is a secure web form. Your information provided here will become part of your Bismarck Surgical Associates Medical Record and will be protected as such.
Depending on timing the Nurse may ask you these questions during the phone interview. Please inform the Nurse you filled this form out on the Web so you do not have to repeat the same information.
**Only complete this form if you are having an Orthopedic Surgical procedure. Pain patients should use the "Pain History & Physical" form.
Please indicate the type of reaction to each.
simply type "none" if you do not take any
If possible include the dosage with prescriptions.
You may be asked to take a Zantac 150mg or Pepcid 20mg one-hour prior to arrival if you will be going to sleep for the procedure. Your nurse will call you the day before to verify if needed.
List the number or numbers you can be reached at the day before your procedure
This is your primary or family physician/practitioner. If you do not have one then type "none".
Please list the name of the responsible adult available for transportation home and 24 hours after surgery. Your procedure will be cancelled if you do not have a responsible person listed.
DO YOU OR HAVE YOU EVER HAD?
Heart & Cardiovascular
Lung & Pulmonary
If you have sleep apnea please indicate in the box above.
Please indicate if you are on dialysis
Please indicate if you have or had MRSA/VRE in the above box
please indicate if "Insulin Dependent" or
Check if any possibility you could be Pregnant
list any health concerns you may have not explained above.
I have read through each of the questions above.
list any surgical procedures in your lifetime.
How many packs per day?
How many years have you smoked?
Do not mark if you have quit.
Alcohol: select the closest match.
It is your option to bring it with on the day of your surgery so we can scan it into your chart.
Thank you for filling out our online registration form. If you do not feel comfortable discussing a particular aspect of your health on this online form you may call us at 701-221-2299 and ask to speak with the phone nurse.