Medical and Anesthesia History

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

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

Elaborate on each answer marked "Yes".

Please provide information on each affirmative answer identifying it 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 - Chapel Hill Tubal Reversal Center can follow-up and provide a copy of your operative report following surgery: