Patient Medical History

English AVSC Patient Medical History

"*" indicates required fields

Name*

First Last

Date of Birth*

Email*

Date of Surgery:

Weight (lbs)*

Height (feet and inches)*

ex. 5'4

Do you have a medical power of attorney (POA)?*

Yes

If YES, please state their name:*

Phone Number:*

Are you able to sign legal documents without your POA?*

Yes

Driver Information: Who is driving you after the procedure?*

Driver’s Phone Number:*

Physician Information

Do you have a primary care physician (PCP)?*

Yes

If YES, please state their name:*

Phone Number:*

Do regularly see any specialists (eg, cardiology, rheumatology, etc.)?*

Yes

If YES, please state their name(s) and specialty:*

Specialist Phone Number:*

If additional, please state their name(s) and specialty:

Specialist Phone Number:

If additional, please state their name(s) and specialty:

Specialist Phone Number:

May we contact your physician(s) if we need additional medical information?*

Yes

Basic Screening

Are you a current or former smoker (cigarettes, cigars, pipes, e-cigarettes, vaporizes, etc.)?*

Never Smoked

Current Smoker

Former Smoker

Do you drink beer, wine, or liquor?*

Yes

If YES, please specify number of drinks per week:*

drinks per week

Do you regularly use marijuana or THC?*

Yes

If YES, please specify type and frequency:*

Do you have a history of using recreational or street drugs?*

Yes

If YES, please specify type and frequency:*

General History

Do you have any dental work done?*

Yes

If YES, please specify:*

Are you wheelchair-dependent?*

Yes

If YES, are you able to transfer from the wheelchair onto a bed? Please specify whether you can do this independently or, if not, what level of assistance you require:*

Do you have non-dental implants, including metal plates/rods/screws, artificial joints, or an internal nerve stimulator?*

Yes

If YES, please specify:*

Medications: Please list all the medications you are currently taking, including both prescription and over-the-counter medications, vitamins, supplements, injectables, patches, eye drops, etc. Please note, you must provide this list even if you have already provided it to the Eye Care Center.*

Alert: If you take any GLP-1 medications, please list this medication in your medication list and reach out to the Advanced Vision Surgery Center nurses to discuss the protocol for this at the following phone number: 720-526-2427 Option 2. GLP-1 medications include the following. Please check the appropriate box if you take one of these medications:

Byetta, Bydureon (Exenatide)

Trulicity (Dulaglutide)

Adlyxin (Lixisenatide)

Victoza, Saxenda (Liraglutide)

Tanzeum (Albiglutide)

Mounjaro (Tirzepatide)

Ozempic (Semaglutide)

Wegovy (Semaglutide)

Rybelsus (Semaglutide)

Allergies: Please list all known allergies to medications, foods, or latex, and list your reactions to these allergens.

Past Surgical History

Do you or a family member have a history of malignant hyperthermia (life-threatening high temperature under anesthesia)?*

Yes

If YES, please specify who and what happened:*

Do you or a family member have a history of pseudocholinesterase deficiency (prolonged paralysis caused by muscle relaxants)?*

Yes

If YES, please specify who and what happened:*

Please list all surgeries or procedures that required anesthesia (including colonoscopies) that you have had within the last 10 years (include procedure, date, and were there any complications, if so please describe):

Do you have any history of:

difficult intubation (placement of a breathing tube)?*

Yes

motion sickness or post-operative nausea and vomiting?*

Yes

serious, adverse reactions to anesthesia medication?*

Yes

If YES to any of the above, please describe:*

Cardiac (Heart) Health

Do you have a pacemaker and/or implanted cardiac defibrillator?*

Yes

If YES, please specify the type(s) of devices and the manufacturer(s):*

Date device was placed:*

Date device was last checked:*

Do you have any cardiac stents?*

Yes

If YES, when were the stents inserted?*

Have you been diagnosed with an abnormal heart rhythm (arrythmia)?*

Yes

If YES: date this was diagnosed:*

Type of abnormal rhythm:*

Do you have a history of heart-related chest pain?*

Yes

If YES: when did you last experience this, and how often did it occur?*

Have you ever had a heart attack?*

Yes

If YES: when did this happen, and what interventions were taken?*

Do you have a history of high cholesterol/lipids?*

Yes

Do you have a history of coronary artery disease (CAD)?*

Yes

Do you have a history of congestive heart failure (CHF)?*

Yes

Do you have a history of heart valve problems?*

Yes

If YES, please specify:*

Do you have a history of high blood pressure?*

Yes

If YES, is your blood pressure well-controlled by medication?*

Yes

For any additional cardiac information you wish to provide:

Pulmonary (Lung) Health

Do you have a history of asthma?*

Yes

If YES, how often do you use an inhaler?*

Have you been diagnosed with sleep apnea?*

Yes

If YES, do you use a CPAP or BPAP?*

Yes

Have you had pneumonia within the last 6 weeks?*

Yes

Do you have any history of chronic obstructive pulmonary disease (COPD)?*

Yes

Do you have any history of tuberculosis (TB)?*

Yes

Have you ever been diagnosed with pulmonary hypertension? (Please note, this is a different condition from high blood pressure.)*

Yes

If YES, is it:*

Mild

Moderate

Severe

Do you use oxygen at home?*

Yes

If YES, how often and how many liters?*

Renal (Kidney) Health

Do you have any history of kidney failure?*

Yes

If YES, please describe severity, whether you are on dialysis, and whether you have a transplant:*

Hepatic (Liver) Health

Do you have any history of liver failure or yellow jaundice?*

Yes

Do you have any history of hepatitis?*

Yes

If YES, what type of hepatitis, when was this diagnosed, and what interventions were taken?*

Neurologic (Nervous System) Health

Do you have a history of dizzy spells or fainting?*

Yes

Do you have a history of dementia?*

Yes

Do you have a history of Parkinson’s disease?*

Yes

Do you have a history of Alzheimer’s disease?*

Yes

Do you have a history of seizures?*

Yes

If YES, when did you last have a seizure?*

Do you have a history of stroke (including transient ischemic attacks/TIAs)?*

Yes

If YES, when did this last occur?*

Other Health

Have you been diagnosed with diabetes?*

Yes

If YES, what type?*

Have you been diagnosed with thyroid disease?*

Yes

If YES, please specify (hypothyroid, hyperthyroid, etc.):*

Do you have any history of cancer?*

Yes

If YES, please specify the type of cancer and treatment received:*

Do you have any history of anemia?*

Yes

Do you have any history of bleeding or blood clotting disorders?*

Yes

If YES, please explain:*

Do you have any history of HIV/AIDS?*

Yes

Are you able to lie flat for this procedure? (You will be provided pillows to place under your legs, and you may have something placed under your neck if needed).*

Yes

Is there anything else you would like us to be aware of?

PLEASE RETURN TO AVSC BY ONE OF THE FOLLOWING:

Email: mhx@avscenter.net

Fax: 833-390-1292

Physical drop off at: 1390 Dry Creek Drive, Longmont CO 80503

If you have any questions, please call us at 720-526-2427 (option 2).

Our Longmont team would Love to answer any questions you have!

The below buttons will redirect you to the Eye Care Center of Northern Colorado website.

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