Black Canyon Surgical Center

Available Forms

PreOp Form

PreOP

Thank you for taking the time to complete this form. We appreciate you choosing Black Canyon Surgical Center for your surgery. Please answer all questions so we may have a thorough medical history for our anesthesia provider. If you have any questions regarding your procedure please call (970) 249-6842. You must complete the form in one sitting. Please complete the form using a desktop computer as cellular phone and Ipad devices may not work.

Patient First and Last Name *

Contact Telephone Number *

Ok to leave detailed messages for preop instructions and postop care follow up?

Yes

Primary Language *

Do you need an interpreter?

Please select *

Yes

Survey completed by:

Completed By: *

Are you completing the form for a child/minor (under the age of 18)?

Yes

If you are a court appointed guardian or custodial parent for medical decisions, we need a copy of the court's paperwork before admission or we will not be able to provide care. Please enter your name below.

Parent/Guardian Name

Parent/Guardian Phone Number

Designated driver/ Responsible adult for 24 hours

Please make certain your driver is available. If the patient is under age 18, an adult must remain in the building at all times. If you do not have a driver, your procedure may be delayed or cancelled.

Name of designated driver

Drivers Telephone Number

Please be aware you are required to have a responsible adult available for 24 hours after surgery.

Yes, I will have a responsible adult available. Please initial *

Please list an emergency contact person

Name

Contact Telephone Number

Allergies/Sensitivites

None

Allergic to Latex

IV Dye/Iodine

Local Anesthetic

Please list all allergies/sensitivites to medication, food, tape, etc AND describe reaction

Medical History

Height *

Weight-Pounds *

Primary Care Physician

Infectious Diseases

Have you had a history of MRSA,VRE, C. Difficile,TB or open sores at this time?

Yes

If yes, please indicate below

MRSA

VRE

C. Difficile

Open sores or wounds

Other

Respiratory

None

Asthma

COPD (Chronic Obstructive Pulmonary Disease)

Recent Upper Respiratory Infection

Sleep Apnea/CPAP

Lung Clots

Other

Cardiovascular

None

Coronary Artery Disease

Chest pain

Heart Attack

When?

High Blood Pressure

Congestive Heart Failure

Irregular Heartbeat

Please list irregular heart beat type

Heart Murmur

High Cholesterol

Pacemaker

Defibrillator

Manufacturer of

Pacemaker or Defibrillator

Are you currently under the care of a cardiologist?

Yes

If yes, please provide name of physician.

Other

Renal/ Endocrine

None

Kidney Failure/Dialysis

Diabetes

Diabetes type

Type I or II

Overactive Thyroid

Under-Active Thyroid

Last menstrual period

Other

Neuro/Musculoskeletal

None

Epilepsy or Seizures

Muscle Weakness/Paralysis

Back or Neck Problems

Arthritis

Stroke/TIA's

Depression / Anxiety

Neuro-Muscular Disease

Dementia/Alzheimers

Other

Gastrointestinal

None

Hepatitis

Please check Hepatitis Type

Liver Disease

Hiatal Hernia

Acid Reflux/Heartburn

Other

Ears-Eyes

None

Cataracts

Glaucoma

Hearing Loss

Other

Hematological-Cancer

None

Bleeding Problems

Please explain

Blood Clots

Please explain

Cancer

Please explain

Anemia

Other

Social History

Any alcohol use?

Yes

If yes, please answer the questions below.

How often?

Current tobacco use?

Yes

If yes, please answer the type below.

Type

Any drug use?

Yes

If yes, please describe below type of drug and how often you use it.

Other

Mobility Limitations

None

Cane/Walker

Wheelchair

Unable to walk/stand

Other

Surgeries

Please list previous surgeries (dates are not necessary unless you have had a recent cardiac/ heart surgery)

None

Previous Surgeries

Anesthesia

Have YOU had any problems to anesthesia or being put to sleep?

None

Nausea/Vomiting

Difficulty Waking Up

Difficult Intubation

Malignant Hyperthermia (increase in body temperature/ fever after receiving anesthesia)

Other, please describe below

Other

Has anyone in the immediate FAMILY (blood relative) had problems to anesthesia or being put to sleep?

None

Difficulty Waking Up

Malignant Hyperthermia (increase in body temperature/fever after receiving anesthesia)

Other, please describe below

Other

Home Medications

Please list all of the medications that you take at home both prescription and over the counter i.e.vitamins; list one medication per line along with the DOSE and how OFTEN you take this particular medication.

For example, enter: Aspirin 81 mg daily

None

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

Medication 11

Medication 12

Medication 13

Medication 14

Medication 15

Medication 16

Medication 17

Medication 18

Medication 19

Medication 20

Other

If you are on more than 20 medications please list the rest here.

Advance Directive/Living Will

Do you have an Advance Directive or a Living Will for medical care?

Yes

If yes, please bring a copy on the day of surgery.

PREOP INSTRUCTIONS

I am aware NOT to eat, drink, use tobacco, chew gum, mints or candy or any kind after midnight. For pain management patients you may have a light meal prior to your procedure. Your procedure may be DELAYED or CANCELLED if you do not follow these instructions. Please call if any questions

I am aware I am to bring my insurance cards, driver's license or photo ID along with a form of payment for my copay/deductible if instructed by our business office.

You will need a responsible adult to sign for discharge instructions and drive you home if any anesthesia or sedation was administered. No driving for 24 hours or if on pain medications. No smoking on day of surgery. A 24 hour caregiver should be available. No jewelry, contacts, nailpolish or artificial nails on surgical extremity. Please leave all valuables at home. No deodorant under surgical shoulders. Do not shave surgical area. Wear comfortable clothing. If you are on any heart or blood pressure medications that you normally take in the morning, please take them the morning of surgery with a small sip of water. Take asthma medications and bring inhalers. If you are on any insulin please consult with your surgeon or primary care physician regarding doses. Do not take any oral diabetic medication the morning of surgery.

I am aware of the need to have a responsible adult and of my pre-op responsibilities *

Please initial that your understand your pre-op responsibilities

Date Of Surgery

Planned Procedure *

Please identify a side if applicable

Thank you for taking the time in completing your preop assesment form. This will ensure we have accurate information to better serve you while you are at our facility. It is always a good idea to carry medical information with you at all times in the event of an emergency. A preop nurse will be contacting you to verify your information, answer any questions you may have and give further instructions. Again, you are welcome to contact us Monday-Friday 8:00am-4:00pm for further assistance (970) 249-6842.

Patient First Name *

Patient Last Name *

Date of Birth *

Please Initial Acknowledgment of the Following: *

I have read and understand the HIPAA Privacy Practice, Patient Rights and Responsibilities, Ownership Disclosure, Advance Directives, Grievance Process and COVID risk acknowledgment documents located on the Black Canyon Surgical Center website (www.blackcanyonsurgicalcenter.com).<br/>

* Required field