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 a Cataract Surgical procedure. Pain patients should use the "Pain History & Physical" form.
Please indicate type of reaction you had to each allergy.
Simply type None if you do not take any medications, just list the name of the medications.
Heart & Cardiovascular-Do you have heart problems?
Please indicate if you have had a heart attack, chest pain, murmur, irregular heartbeat, valve problems, pacemaker, bypass, stents, etc
Do you have high blood pressure?
Please indicate any other Heart Issues
Lung & Pulmonary- Do you have any breathing problems?
Please describe the breathing issues you have. Asthma, Emphysema / COPD, Sleep Apnea, Shortness of breath, etc.
Neurological-Have you ever had a stroke or seizures?
Please indicate when you had your stroke or last seizure
Social History -Do You Smoke?
Indicate how many packs per day you smoke.
Indicate approximately how many years you have smoked
Indicate what year you quit smoking.
indicate how often you use alcohol : Never, Daily, 1-2 times a week, Seldom-1-2 times a month, Rarely 1-2 times a year
Are you Diabetic?
Please Indicate Insulin Dependent or Non-insulin dependent
Do you have any Thyroid or Kidney problems?
Describe any thyroid or kidney problems / kidney stones you have or had in the past
Do you have any Stomach Problems?
Please explain if Hiatal Hernia issues:
Please explain if you have had ulcers in the past or currently have ulcers.
Please explain if you have acid reflux disease or had problems with it in the past
Please explain if you have history of heartburn or having problems currently
Other health issues
List any other health issues you have.
Please list the type of surgeries you have had in your life time. You do NOT need to indicate the year of the surgery.
Do you have problems with local or general anesthesia
Please indicate what kind of problems such as nausea vomiting high fever OR if there is any family history of anesthesia problems.