Dr. Paul Pre-op Questions
Thank you for your time. After you complete this form, we will send an email from PhysioOutcomes with pre-op information specific for your surgery.
Your Full Name
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First Name
Last Name
Your Email
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example@example.com
Date of Birth
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Month
-
Day
Year
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Phone Number
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Area Code
Phone Number
What is your surgery date if you know it?
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Month
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Day
Year
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What surgery are you having?
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Check the conditions that apply to you or to any members of your immediate relatives:
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Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Check the symptoms that you're currently experiencing:
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Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
List any blood thinners you are taking including Goody Powders
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List any drug allergies you have
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How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
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