Southwest Lincoln Surgery Center

The fields marked with * are required

Patient Name:

*First:

Middle Initial: *Last:

*Date Of Birth:

(MM/DD/YYYY)

*Address:

City / State / Zip:

*City:

*State: *Zip:

*Best Phone Number
To Be Reached At:

XXX-XXX-XXXX

Best Time To Call:

Alternate Phone Number:

XXX-XXX-XXXX

Doctor:

Scheduled Procedure:

Scheduled Date of Service:
(MM/DD/YYYY)

Scheduled Procedure:

Height / Weight:

Height:

Weight: lbs.

Contacts / Dentures:

Contacts? Yes No

Dentures? Yes No

Braces / Loose Teeth:

Braces? Yes No

Loose Teeth? Yes No

Neurological:

You:
Stroke
Epilepsy
Seizures
Fainting
Migraines
Speech Deficit
Dizziness
Other:

Blood Relatives:
Stroke
Epilepsy
Seizures
Fainting
Migraines
Speech Deficit
Dizziness
Other:

Eyes, Ears, Nose & Throat:

You:
Sinus Problems
Ear Infection
Glaucoma
Hard Of Hearing
BlindnessRightLeftBoth
Other:

Blood Relatives:
Sinus Problems
Ear Infection
Glaucoma
Hard Of Hearing
BlindnessRightLeftBoth
Other:

Cardiovascular:

You:
Angina
Heart Attack
Congestive Heart Failure
Rapid Or Irregular Heart Beat
Pacemaker
Rheumatic Fever
Peripheral Vascular Disease
Other:

Blood Relatives:
Angina
Heart Attack
Congestive Heart Failure
Rapid Or Irregular Heart Beat
Pacemaker
Rheumatic Fever
Peripheral Vascular Disease
Other:

Respiratory:

You:
Bronchitis
Asthma
Pneumonia
COPD
Sleep Apnea
Other:

Blood Relatives:
Bronchitis
Asthma
Pneumonia
COPD
Sleep Apnea
Other:

GI/GU:

You:
Peptic Ulcer
Hiatal Hernia
Liver
Ostomy
Nausea
GERD
Dialysis
Kidney/Bladder Infection
Other:

Blood Relatives:
Peptic Ulcer
Hiatal Hernia
Liver
Ostomy
Nausea
GERD
Dialysis
Kidney/Bladder Infection
Other:

Endocrine:

You:
Diabetes
Thyroid
Other:

Blood Relatives:
Diabetes
Thyroid
Other:

Skin:

You:
Rash
Ulcers
Wounds
Other:

Blood Relatives:
Rash
Ulcers
Wounds
Other:

Musculoskeletal:

You:
Arthritis
Osteoporosis
Fracture
Back Pain
Other:

Blood Relatives:
Arthritis
Osteoporosis
Fracture
Back Pain
Other:

Blood:

You:
Bleeding/Clotting Problems
Tranfusion Reactions
Sickle Cell
Other:

Blood Relatives:
Bleeding/Clotting Problems
Tranfusion Reactions
Sickle Cell
Other:

Infectious Diseases:

You:
Hepatitis
TB
AIDS
HIV
MRSA
VRE
STD
Other:

Blood Relatives:
Hepatitis
TB
AIDS
HIV
MRSA
VRE
STD
Other:

Communicable Diseases:

You:
Measles
Chicken Pox
Mumps
Rubella
Recent Exposure
Other:

Blood Relatives:
Measles
Chicken Pox
Mumps
Rubella
Recent Exposure
Other:

Mental Health:

You:
Emotional Problems
Depression
Bipolar Disorder
Other:

Blood Relatives:
Emotional Problems
Depression
Bipolar Disorder
Other:

Anesthesia:

You:
Problems With Anesthesia
Malignant Hyperthermia
Other:

Blood Relatives:
Problems With Anesthesia
Malignant Hyperthermia
Other:

Menstrual period:

Are You Currently Menstrating?
Yes No N/A

Date of Last Monthly Period
(MM/DD/YYYY)

Allergies:

Medications:

Please list all prescription and over the counter medications:

Name of Medication	Dosage	How Often	Why

Previous Surgeries:

Please list all previous surgeries:

Surgery	Date
		(MM/DD/YYYY)
		(MM/DD/YYYY)
		(MM/DD/YYYY)
		(MM/DD/YYYY)
		(MM/DD/YYYY)

Did you have pain after surgery?
Yes No N/A

What pain meds worked for you?

Driver / Caretaker:

Who will you be bringing with you?

Relationship to you:

Discharge Plan:

*Who will be driving the patient home?

*Phone number of person driving you home:XXX-XXX-XXXX

Rights & Responsibilities:

I have read and understand the Patient Rights & Responsibilities:
You must check "Yes" for form to be submitted Yes No

Note: Minor children need to know the legal guardian and bring legal paperwork to the surgery center day of surgery. All minor patients require a parent to stay in the facility during surgery.