Surgery Scheduling Request Form

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Surgery Scheduling Request
Date ____________________________
Urgent
Patient Name _____________________________________________________________________________
Diagnosis and ICD-9 Codes
Past Medical History
Yes
No
__________________________________________
Heart Disease
Chest Pain
__________________________________________
Shortness of Breath
Arrhythmia (Irregular Heart Beat)
__________________________________________
Mitral Valve Prolapse (MVP)
Hypertension (High Blood Pressure)
Procedure
Blood Clot / Pulmonary Embolism
Chronic Lung Disease / Asthma
Hysteroscopy
D&C
Novasure
Sleep Apnea
Acid Reflux / GERD
LEEP
CKC
HSG
GI Bleed
Liver Disease
Laparoscopy
BTL
LOA
Diabetes
Thyroid Disease
Holmium Laser
TAH
BSO
Anemia / Blood Disorder
Cancer
Harmonic Scalpel
TVH
LSO
Stroke / TIA
Seizure Disorder
Chromopertubation
LAVH
RSO
Kidney Disease
Back / Neck Problems
Anterior Repair
Posterior Repair
Family History of Heart Problems
EX LAP
Lymph Nodes
Previous Anaesthesia Problems
Primary C/S
Repeat C/S
Tobacco Use
Alcohol Use
Other ____________________________________
Recreational Drug Use
___________________________________________ ____________________________________________
Previous Surgery
Facility
TCH
GSH
BN
__________________________________________
PAT / Lab
__________________________________________
Type & Screen
H/H
CBC
_____________________________________________
Urine Pregnancy
EP1
PFT's
__________________________________________
Serum Pregnancy
PT
PTT
__________________________________________
Coag Profile
CXR
EKG
___________________________________________ _____________________________________________
Surgery Date ________________________________ __________________________________________
Arrival Time ___________________________________________________________________________
Surgery Time __________________________________________________________________________
Street Address _____________________________ Home Phone ______________________________
City _______________________________________ Work Phone _______________________________
State / Zip ________________________________
SSN
___________- ___________- _____________
Height _____________ Weight ______________
Age ____________
LMP ______________ G ________ P ________
DOB
__________ / __________ / ____________
Patient to Complete Area
Inside the Box

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