Medical and Anesthesia History

Please complete this form within 24 hours after you have scheduled the date for your tubal reversal. This medical and anesthesia history form will be submitted to us online when you press the Submit button after typing in your information. Please contact us if you have any questions.

Please be sure the form is complete and accurate. This information is to ensure your health and safety when Dr. Berger performs your tubal reversal surgery. Providing inaccurate information will result in your surgery being delayed or cancelled.

All items with an asterisk must be completed to submit the form. If an item is not applicable (for example if you don't have a work or cell phone number, type in "none" or "not applicable".

Do not submit this form until after you have scheduled your procedure with our office.

* Your first name
* Your middle initial
* Your last name
* Date of birth
* Date of surgery
* Height
* Weight

How may we contact you?

Email
Work phone
Home phone
Cell phone

The adult who will accompany me on the day of surgery is:

* Name
* Relationship
* Cell phone

All the questions below require an answer:

1. Have you ever been "put to sleep" or received anesthesia?Yes No
2. Have you ever had a problem due to anesthesia?Yes No
3. Has any family member had a problem with anesthesia?Yes No
4 . Have you ever been hospitalized for non-surgical problems?Yes No
5. Do you take any prescription medications?Yes No
6. Do you take herbal medications or supplements?Yes No
7. Have you ever received a steroid or cortisone medication?Yes No
8. Are you allergic to or had an adverse reaction to medicine?Yes No
9. Have you ever had a problem with your lungs?Yes No
10. Do you currently have a respiratory infection (a "cold")?Yes No
11. Have you ever had heart or blood pressure problems?Yes No
12. Have you ever had hepatitis or a problem with your liver?Yes No
13. Have you ever had a problem with your kidneys?Yes No
14. Have you ever had thyroid disease?Yes No
15. Do you have diabetes?Yes No
16. Have you ever had a problem with seizures or epilepsy?Yes No
17. Do you have any eye disease (such as glaucoma)?Yes No
18. Do you have any loose, false, capped or chipped teeth?Yes No
19. Do you have any type of back or neck problems?Yes No
20. Do you have any muscle weakness?Yes No
21. Have you ever received a blood transfusion?Yes No
22. Have you ever had a blood transfusion reaction?Yes No
23. Have you ever had excessive bleeding with surgical or dental procedures?Yes No
24. Have you ever seen a nerve specialist?Yes No
25. Do you smoke?Yes No
26. Do you use alcohol?Yes No
27. Have you ever had a history of drug abuse?Yes No
28. Do you have a healthcare power of attorney or advance directive? If so, please bring a copy with you when you come for surgery.Yes No

Please elaborate on each answer marked "Yes", identifying each affirmative answer with the number corresponding to the specific question:

Please provide your doctor's name and complete address in the space provided so that - with your permission - Dr. Berger can follow-up and provide a copy of your operative report following surgery:

I would like Dr. Berger to send my operative report to my doctor:Yes (provide details below) No

My Doctor's Name:
Doctor's Address line 1:
Doctor's Address line 2:
Doctor's City State Zip Code:

My doctor referred me to Dr. Berger:Yes No

I have answered the questions accurately and provided details of any answered yes.

For security purposes, please type the sequence of numbers and letters below:

If you have trouble submitting this form, please contact us.

Special Report

Answers to seven important questions to find out if tubal reversal is right for you.

Call (919) 968-4656 To Speak With a Tubal Reversal Nurse

109 Conner Drive Suite 2200, Chapel Hill, NC 27514 (919) 968-4656