Charles River Pre medical and medication form

Charles River Endoscopy Pre-Procedure Medical Form

Name: _______________________________________Height: _________    Weight: __________

Primary Care Physician:                                                                          Pharmacy Info:                                  

Name first and last name: _____________________Name: ______________________

Location:  ______________________           Location: ___________________________ 

Please list any other Medical/Surgical History/ hospitalizations or other problems/ concerns that you have: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any relevant family history: ___________________________________________________________________________________

Yes    No     Have you or any family members ever have any problems with anesthesia in the past? Type: _____________

Yes    No     May we leave a message on your home/cell answering machine regarding your care?

Yes    No     Can we discuss the procedure with anyone other than you (i.e. your ride, primary care, family etc.)

Do you use (circle that apply):      eyeglasses     contacts     hearing aids     dentures

Yes    No     Latex Allergy/ Egg/ Soy/ Nut? (please circle any that apply) & Reaction: ____________________________________                       

Medication Allergy (if present, please list the reaction)? ____________________________________________________________

Other Allergy (if present, please list the reaction)? ________________________________________________________________

Please List ALL Current Medications/Vitamins (Prescriptions AND Over the Counter)

on the back of this sheet

Medication                                         Dose                Frequency                    Last Dose

Patient Signature: _______________________________________________ Date: _______________

 Nurses Signature:_______________________________________________ Date: _______________

This information has been reviewed and updated with the patient prior to the procedure.                                                              

Copy of Bill of Rights, Informed Consent & Privacy Policy given to patient to review prior to procedure.