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