Patient Pre-Registration and History - No Anesthesia

Date of Surgery

Surgeon

Last Name

First Name

Middle Initial

Preferred Name/Nickname

Gender

Male Female

Date of Birth

Social Security #

Marital Status

Married Single Divorced Widowed

Home Address

Home #

Cell #

Work #

E-mail Address

E-mail Address

Patient Employer

Phone #

Primary Insurance

Policy #

Group #

Name of Subscriber

Relationship

Subscriber Employer

Subscriber Date of Birth

Subscriber S.S. #

Secondary Insurance

Policy #

Group #

Name of Subscriber

Relationship

Subscriber Employer

Subscriber Date of Birth

Subscriber S.S. #

Notify in Emergency: (other than spouse)

Home #

Cell #

Work #

Family Physician/Pediatrician

Phone #

Do you currently see a heart doctor?

Phone #

What other specialists/doctors do you see?

Current Height

Current Weight

List the medications you are currently taking, the dose and time of day you take them

List any ALLERGIES to medications, iodine/contrast dye, latex tape or food. Include Reaction.

List any surgeries/major illnesses (including cancer) you have had, and approximate date.

Have you or a blood relative ever had a complication/reaction from anesthesia? (fever, difficulty awakening, nausea, airway complications)

Yes No

Have you been hospitalized at Shawnee Mission Medical Center within the last year?

Yes No

Heart Failure High Blood Pressure MI/Heart Attack Pacemaker/Defibrillator Bleeding Tendencies

Emphysema/COPD Asthma w/ Inhaler Asthma w/o Inhaler

Stroke Weakness Alzheimer's Dementia

Tuberculosis Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

Diabetes (Type I) Diabetes (Type II) Use Insulin

list6

Glasses Contacts Hearing Aid

Use cane/walker/wheelchair

Will anyone be coming with you?

or Reset

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Main Hospital Number

913-676-2000

9100 West 74th Street

Shawnee Mission, Kansas 66204

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913-676-7777

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