Admission Health Survey - Vail Valley Surgery Center
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2VAIL VALLEY SURGERY CENTER VAIL
admission health survey short form
Dear Patient: This Short Form Health Survey is designed to help us speed you through the admission process.
Please circle / answer the following questions: Yes, No, ? = unsure/unknown. Please comment when indicated.
It is important to provide accurate and complete information. Thank You.
Height __________________
Weight __________________ ___________ Comments
Have you ever had problems with anesthesia?
Yes No ? _________________________________________
Has anyone related to you ever had a problem with anesthesia?
Yes No ? _______________________________________
Do you have any lung or respiratory problems? Sleep Apnea?
Yes No ? _______________________________________
Have you had a “cold” recently?
Yes No ? _______________________________________
Have you had a chest xray in the past 6 months? Or EKG?
Yes No ? _______________________________________
Do you have high blood pressure?
Yes No ? _______________________________________
Do you have any heart conditions or problems?
Yes No ? _______________________________________
Do you get chest pressure or pain with exertion or at rest?
Yes No ? _______________________________________
Do you get winded walking up stairs?
Yes No ? _______________________________________
Have you noticed an irregular heartbeat?
Yes No ? _______________________________________
Do you have diabetes or high blood sugar?
Yes No ? _______________________________________
Do you have kidney or bladder problems? Prostate?
Yes No ? _______________________________________
Do you have any thyroid problems or take thyroid medications?
Yes No ? _______________________________________
Do you have arthritis, joint problems, or connective tissue disease?
Yes No ? _______________________________________
Have you ever had liver problems like hepatitis?
Yes No ? _______________________________________
Do you have frequent indigestion, hiatal hernia, or ulcers?
Yes No ? _______________________________________
Do you have anemia, sickle cell or have you had a blood transfusion?
Yes No ? _______________________________________
Do you have bleeding problems or bruise easily?
Yes No ? _______________________________________
Do you have back problems or other physical disabilities?
Yes No ? _______________________________________
Do you have neurological problems? Seizures?
Yes No ? _______________________________________
Could you be pregnant? Note date of last menstrual period if applicable.
Yes No ? ________________________LMP____________
Do you wear contacts or glasses?
Yes No ? _______________________________________
Do you have a hearing aid, or have any surgical implants?
Yes No ? _______________________________________
Do you have loose or damaged teeth, caps, or dentures?
Yes No ? _______________________________________
Do you ever use tobacco products?
Yes No ? _______________________________________
Do you, or have you ever used alcohol?
Yes No ? _______________________________________
Do you use any “recreational” drugs?
Yes No ? _______________________________________
Are you “at risk” for HIV or any sexually transmitted disease?
Yes No ? _______________________________________
vail valley surgery center
admission health survey short form (english)
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