Feel free to fill this out and submit it online before you come in for surgery.

Cardiovascular

Are you now or have you ever been treated for:

Heart Trouble: YES NO

Heart Murmur: YES NO

Heart Attack:    YES NO

Angina/Chest Pain: YES NO

Pacemaker: YES NO

Irregular Pulse: YES NO

Congestive Heart Failure: YES NO

Blood Pressure: YES NO N/A

EKG In Last 3 Months: YES NO
Date: / /

Doctor:

Comments:

Nuerological

Are you now or have you ever been treated for:

Head Injury: YES NO

Seizures/Convulsions: YES NO

Blackout Spells:    YES NO

Stroke: YES NO

Severe Headaches: YES NO

In The Past 2 Weeks Have You Taken:

Tranquilizers: YES NO

Comments: