Mohs Pre-Operative Health Form 1 2 General Information 3 Allergies and Medications 4 Past and Present Conditions PLEASE REVIEW THE WOUND CARE INSTRUCTION SHEET PRIOR TO YOUR SURGERY SO THAT YOU CAN PURCHASE NECESSARY SUPPLIES. BE AWARE THAT YOU WILL HAVE A 10 POUND LIFTING RESTRICTION AND WILL NEED TO STAY OUT OF THE WATER FOR 2 WEEKS AFTER YOUR SURGERY. Previous Next General Surgery Information: Surgeon you are scheduled with Surgery date Surgery Site (on body) Your Name Age Phone Number Height Weight Previous Next Allergies and Medications Are you currently taking any of the following medications: Coumadin Insulin Antibiotics Digoxin Steroids Aspirin Vitamin Other medications, drugs, or vitamins you are taking at the present time: Do you have Dentures? YesNo Please list any current Allergies: Previous Next Past and Present Conditions Do you have or have you ever had any of the following conditions: DiabetesHeart trouble (disease)Heart trouble (surgery)AsthmaBleeding tendenciesEmboliHepatitisPacemaker / defibrillatorGlaucoma High blood pressureKidney troubleCancer (Other than Skin)EpilepsyRheumatic FeverBlood transfusionProsthetic joint or valvesHistory of MRSA infectionOther Mahalo for taking the time to complete our form. Please provide your email address if you would like to receive a copy of this form: Previous Next
