| Document Date: 2014-04-16 13:11:43
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Facility Implantable IV Port / / MedicalCondition Allergy / Y Lung Problems Urinary Tract Infections / Allergies / Other Allergies / AIDS High Blood Pressure Cancer / antibiotics Emotional Illness Elevated Cholesterol Depression / Cholecystectomy Cataract / Heart Problems Heart Attack MSRA / Herbal Products Dose Frequency Allergies Yes No Describe Reaction Allergies / loss Persistent cough / Vision Problems Prostate Enlargement Neurologic/Seizure Disorder Penile Prosthesis Degenerative Arthritis Diabetes I / bacterial infections / / MedicalTreatment invasive procedures / Total knee replacement / surgeries / Total hip replacement / Cataract surgery / antibiotics / / ProgrammingLanguage Latex / /
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Pre‐Surgical Medical History Name:_______________________________ Patient ID:________________ Date:___________