(100 Days to Health - Nurse Julie Intake)
First Name
Last Name
Date of birth
Phone
*
Email
*
Allergies:
Do you have any allergies to the following?
Antibiotics
Pain medications (opioids, NSAIDs, etc.)
Anesthesia
Latex
Adhesives or surgical tape
Contrast dye
Iodine
Shellfish
No known allergies
(Select all that apply)
If yes, please list reactions:
Are you currently taking any blood thinners?
Yes
No
If yes, which ones?
Eliquis
Xarelto
Pradaxa
Warfarin (Coumadin)
Plavix
Brilinta
Aspirin
Other
Other (please specify):
Do you take herbal or supplement products that affect bleeding?
Fish Oil
Turmeric
Garlic
Ginkgo
None
Other
Are you currently using any of the following?
Ozempic
Wegovy
Mounjaro
Trulicity
Zepbound
Other
None
If yes, date of last dose:
Have you been diagnosed with diabetes?
No
Type 1
Type 2
Do you use insulin?
Yes
No
Do you know your most recent A1c?
Have you been diagnosed with high blood pressure?
Yes
No
Are you on medication for blood pressure?
Yes
No
Is your blood pressure currently well controlled?
Yes
No
Not sure
Have you ever had any of the following?
Heart attack
Stent
Bypass surgery
Heart failure
Irregular heartbeat (AFib)
Pacemaker or defibrillator
None
(Select all that apply)
Do you have any of the following?
Asthma
COPD
Sleep apnea
Use CPAP
Use oxygen
None
Do you currently use any nicotine products?
Cigarettes
Vaping
Nicotine gum/patch/Zyn
None
Have you ever had complications with surgery or anesthesia?
Yes
No
If yes, what happened?
Do you currently have any of the following?
Fever
Skin infection
Dental infection
Urinary tract infection
Respiratory infection
COVID-19
None
(Select all that apply)
Have you ever been told you need medical clearance before surgery?
Yes
No
Not sure
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