Greg Ruff, md 55 Vilcom Center Ste 310



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Greg Ruff, MD

55 Vilcom Center Ste 310

Chapel Hill, NC 27514

Pre-Anesthesia Form




Name:_____________________


Cell #:_____________________


Home#:____________________

Work#:___________________


Age:_________________


DOB:_______________

Allergies:___________


__________________

Weight:_________lbs


Height:___________

Procedure:__________


___________________

Surgeon:____________________________ Surgery Date:__________________________



Cardiovascular Yes No Comments

  1. Have you ever had a heart attack, chest pain, heart murmur ☐ ☐ ________________________
    or an irregular heartbeat?

  2. Do you have a pacemaker or internal defibrillator? ☐ ☐ ________________________

  3. Have you ever had High or Low blood pressure? ☐ ☐ ________________________

  4. Have you had a 12 lead EKG in the last 12 months? ☐ ☐ ________________________


Hematology

  1. Have you ever had problems with your blood clotting ☐ ☐ ________________________

(i.e. easy bleeding or blood clots)?
Respiratory

  1. Have you ever had asthma, bronchitis, emphysema, ☐ ☐ ________________________

pneumonia, TB or sleep apnea?

  1. Do you use a CPAP? ☐ ☐ ________________________

  2. Do you experience shortness of breath with climbing stairs ☐ ☐ ________________________

and/or routine activities?

  1. Have you had a recent cold, cough, fever ☐ ☐ ________________________

night sweats, fatigue or weight loss?
Neurovascular

  1. Do you have motion sickness or vertigo? ☐ ☐ ________________________

  2. Have you ever had a seizure or stroke? ☐ ☐ ________________________

  3. Do you have numbness or tingling in your hands or feet? ☐ ☐ ________________________


GI

  1. Have you had a hiatal hernia, ulcer, acid reflux? ☐ ☐ ________________________


Endocrine

  1. Are you diabetic? ☐ ☐ ________________________

If yes, circle one: Insulin Insulin Pump PO Medications Diet Control


Hepato-Renal

  1. Have you ever had jaundice, hepatitis or cirrhosis of the ☐ ☐ ________________________
    liver?

  2. Have you ever had any problems with your kidneys? ☐ ☐ ________________________



Yes No Comments
General

  1. Do you have any major illnesses not listed above? ☐ ☐ ________________________

  2. Have you or any blood relative ever experienced any ☐ ☐ ________________________

complications related to anesthesia?

  1. Do you have a previous history of nausea and vomiting ☐ ☐ ________________________

after surgery?

  1. Do you wear contacts, eye glasses or hearing aides? ☐ ☐ ________________________

  2. Do you have loose or false teeth or cap/crowns/bridgework? ☐ ☐ ________________________

  3. Do you use marijuana, cocaine, or other similar drugs? ☐ ☐ ________________________

  4. If yes, what and how often? __________________________

  5. Do you drink alcohol? How many per Day/Month? ☐ ☐ ________________________

_________________________________________________

  1. Do you smoke? If yes, per day _______ Years__________ ☐ ☐ ________________________

  2. Could you be pregnant? LMP:_______________________ ☐ ☐ ________________________

  3. Are you breast feeding? ☐ ☐ ________________________

  4. Do you have any religious restrictions to your health care? ☐ ☐ ________________________

  5. Do you have a history of surgical site infections? ☐ ☐ ________________________

  6. Do you have any implants, catheters, ports, pacemaker ☐ ☐ ________________________

or metal in your body?

  1. Any history of Anesthesia problems with previous ☐ ☐ ________________________
    Anesthetics?

  2. Any family or personal history of Malignant Hyerthermia? □ □ _____________

(elevated temperature following surgery)

  1. Do any of the following apply to you?

Current hospitals stay of greater than 3 days prior to

this surgery? ☐ ☐ ________________________



ANY hospitalization during the preceding 90 days? ☐ ☐ ________________________

Dialysis? ☐ ☐ ________________________

Prior history of infection or colonization with ☐ ☐ ________________________
MRSA?

Prior (last 90 days) residence in a nursing home, ☐ ☐ ________________________

rehab facility or home IV care program?

Please list all previous surgeries with Anesthesia and hospitalizations: _________________________

_____________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Please list all current medications: _______________________________________________________

_____________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

_________________________________________________ _________________ _________



Patient signature (if form is completed by patient) Date Time


Revised 04-26-17


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