Patient Health History Form

PLEASE COMPLETE THIS FORM AND BRING IT WITH YOU ON THE DAY OF YOUR SURGERY.

    YesNo

    Doctors

    please List all the doctors involved in your care

    Name

    Reason(ex. heart, diabetes)

    Phone

    Medication Allergies

    NAME OF MEDICATION

    TYPE OF REACTION

    IODINETopicalInjected IVTapePaperClothLatex

    Anesthesia reactions:

    Medical HistoryPlease Check All That Apply

    SCOTTSDALE EYE SURGERY CENTER, P.C.

    I DO NOT TAKE ANY MEDICATION

    Please list all the medicines you take which require a doctor’s prescription.

    Name of Medicine

    Dose of Medicine Mg, Units, cc's

    How Often Taken

    NONEAntacidsAspirin Containing ProductsCold/Cough remediesDiarrhea PreparationsEye DropsHerbal RemediesLaxativesPain MedicinesSleeping MedicineVitamin/SupplementsRecreational DrugsWeight Loss MedicationsOther

    YesNo

    None

    DATE

    PROCEDURES