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Doctor Checking a Form

Patient Forms

You can now conveniently fill out our new patient forms online.

This is the standard form from the American College of Rheumatology.

General Information

Medical History
Are you allergic to or had a bad reaction to any of the following? If yes, please tick the appropriate box/boxes
Are you allergic to or had a bad reaction to any of the following? If yes, please tick the appropriate box/boxes
Surgical History
Protection Compliance Declaration
Please read the following carefully and check if you agree, in the box provided.
Are you allergic to or had a bad reaction to any of the following? If yes, please tick the appropriate box/boxes.

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Pre-Op Instructions & Checklist

1. Your surgery has been scheduled at the following facility. You will be contacted about the time of your surgery. Please arrive at the main admitting desk at least 1-2 hours before your surgery time.

2. Please be available by phone the night before/day of surgery in case there is a change in the schedule, which may require you to arrive earlier/later. The Anesthesiologist may contact you before surgery to review your health status.

 

3. EATING & DRINKING. Do not eat or drink anything after midnight before your surgery. This means no coffee/tea, juice, water, food, hard candy or even chewing gum.

 

4. MEDICATIONS. Please discontinue taking aspirin or any product containing aspirin one week prior to surgery. The non-steroidal antiinflammatory (NSAID’s) medicine such as Advil, Motrin, Aleve, Ibuprofen, Voltaren/ Cataflam should be discontinued 24 hours prior to surgery. If you are currently taking Coumadin/Warfarin, we will have to coordinate that with your Family physician &/or the Anticoagulation Clinic. Please discontinue all herbal supplements & Vitamin E two weeks prior to surgery as they may interfere with the anesthesia.

If you take any other medications, please check with your primary care doctor—some medicine should wait to be taken until after surgery. If you have a medicine that needs to be taken that morning, you may take it with a sip of water.

***It is imperative that we have a current detailed medication list with doses & directions. 

 

5. You may be given a surgical scrub brush to wash the surgical body part and surrounding area the day before and morning of surgery. This is an antibacterial soap that will help kill germs & reduce the risk of post-op infection. DO NOT SHAVE the surgical area for three days before surgery, as this can leave small openings in the skin, which can be entry points for bacteria.

 

6. Wear loose fitting, comfortable clothing to the hospital. A gown and robe will be provided for you upon arrival. Please do not bring anything valuable—leave jewelry & valuables at home.

 

7. Please arrange for a family member or a friend to take you home a few hours after surgery. All patients must be accompanied by an adult escort for discharge. You will not be allowed to drive yourself home nor take a taxi/bus if you are alone.

 

8. Please notify us immediately if you have developed any type of illness or infection (flu, cold, fever etc.). We would also like to know if you have an open sore, rash or skin irritation near the surgical site.

 

9. Do not make any sudden changes in your diet. Eat as you normally would and try to keep your diet consistent. See the enclosed handout from our Nutrition Department for some post-op guidelines.

 

10. Your 1st Post-op appointment has been made to come see us in 1-2 weeks.

 

11. Your physician may have you wear a special knee brace or deluxe sling after your surgery, which will be provided to you before surgery and you will need to bring it to surgery with you.

 

12. Please read your Post-op Instructions before your surgery so that you know what to expect. If you have any further questions, please don’t hesitate to contact us at 1(246) 258-3902. We wish you a speedy recovery.

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Post-Op Instructions

Dr. Adams

1(246) 258-3902

1. After your procedure, you must be driven home & accompanied by an adult who is able to assist you. The anesthesia used during your surgery can make you feel a little off for a day or two. During that time, you should not drink alcohol, make any important decisions or engage in any potentially hazardous activities.

 

2. It is very common to be slightly nauseated after surgery and anesthesia. You should start with a light mild diet until your appetite comes back. It is also very important at this time to stay hydrated by drinking plenty of water and other clear fluids. Taking pain medicine on an empty stomach can also contribute to stomach upset so make sure you eat something with your medication.

 

3. Post-operative constipation can result due to a combination of inactivity, anesthesia and pain medication. To help prevent post-op constipation, you should increase your water & fiber intake the weeks before & after surgery. Physical activity stimulates the bowel and helps your body get back to normal so try to remain as active as possible while still protecting the surgical area. If you do experience constipation, you may try taking Metamucil powder or Dulcolax (stool softeners) as directed. If these do not work, please contact your primary care physician.

 

4. You will need to bathe with a washcloth for the first 2 days after surgery while the dressings are in place. For most procedures, including arthroscopy and shoulder surgery, you may remove your dressings after 5 days and take a shower. You should NOT submerge the incision in a bath, pool or hot tub until the sutures are out & the wound is healed. If you have had an open procedure (like an ACL) on your knee, you should wait until after your first Post-op visit before you can shower safely. Your first visit should be 5–7 days after surgery. They will remove your dressings and instruct you on how to shower safely. The main concern here is stability—if you do not have safety bar/railing in your shower, you may want to use a chair for support.

 

5. If you have had a fracture repair or surgery that requires a hard postoperative splint, this MUST NOT BE REMOVED until your post-op visit and MUST BE KEPT DRY during bathing. There are “cast covers” for bathing that can be purchased at local drug stores.

 

6. If you have been given a brace or sling to use, please use it full-time until your post-op visit where we will instruct you on further use. You may open the brace for icing your knee and remove the sling for bathing. Crutches are used for complex knee/ankle surgeries but they are often not necessary for arthroscopic surgery. We will discharge you with specific instructions.

 

7. It is fairly common to have a low-grade fever for a day or two after surgery. You may take Panadol as directed for the fever. If your fever lasts more than a few days or is greater than 101.5 please call us. Your physician may discharge you with additional instructions. Please read your discharge papers. 

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Elective Admission/ Surgery H&P Form

H & P Valid 30 days from completion

Past History

Review of Systems
General
HEENT:
Neck:
Cardiovascular:
Pulmonary:
GI:
GU:
Extremities:
Skin:
Neuro:
If yes, is smoking cessation counseling provided?

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Tobacco Use
Alcohol Use
Recreational Drugs

Elective Admission/ Surgery H&P Form

Physical Examination Form

Physical Examination

Pertinent Labs

Radiology
EKG/ECHO/OTHER

Vital Signs

Check if Abnormal

Constitutional
Eyes
Respiratory
Genitourinary
Skin
Lymph Nodes
Neck
Cardiovascular
Gastrointestinal
Musculoskeletal
Extremities

* APRN/NP/PA completing H&P consultation require MD co-signature.

EKG

  • Males over 50 (these are the only routinely suggested tests)

  • Females over 50 (these are the only routinely suggested tests)

  • Any history of cardiac disease or severe hypertension

  • Highly invasive procedures

  • Diabetics over 40

CHEST X-RAY – RARELY INDICATED EXCEPT FOR:

  • Cardio Pulmonary disease which is debilitating or with change of symptoms or exacerbation in past 6 months

  • Highly invasive thoracic surgery

PULMONARY FUNCTION TESTS – RARELY INDICATED AS ANESTHESIA SCREENING TESTS

They are indicated for major thoracic surgery

HEMATOCRIT, PLATELET COUNT, WBC

Indicated by patient history, i.e.; Anemia, Chemo Rx or anticipated large blood loss

COAGULATION TESTS

Only indicated for patients with a history of a bleeding disorder or for those undergoing highly invasive vascular procedure.

ELECTROLYTES, BUN/CREATINE, GLUCOSE

Indicated by patient’s history. BUN may be indicated in elderly patients having invasive procedures. Chronic use of diuretics is not an indication for K+ testing in otherwise healthy, active patients.

NPO REQUIREMENTS

ADULT

No solid food after midnight

Clear fluids until 4 hours prior to scheduled arrival at hospital.

CHILDREN OVER 1 YEAR OLD

NPO 6 hours pre-op for solids

NPO 4 hours pre-op for breast milk

Offer clear fluids up to 2 hours pre-op

CHILDREN UNDER 1 YEAR OLD

NPO 6 hours for solid foods

NPO 4 hours for breast milk

Offer clear fluids up to 2 hours pre-op

PRE-OP MEDICATIONS

Patient should take all routine meds for the morning of surgery except insulin and oral hypoglycemic drugs. Glucophage should be discontinued 24 hours prior to surgery.

The surgeon should give specific instructions about anticoagulants, ASA and NSAID’S.

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Elective Admission/ Surgery H&P Form

Admission Reconciliation Form

LIST BELOW ALL OF THE PATIENTS MEDICATIONS PRIOR TO ADMISSION INCLUDING: RX, OTC, HERBAL MEDS, BLOOD DERIVATIVES, NUTRICEAUTICALS, RECENT VACCINATIONS, VITAMINS, RESPIRATORY MEDS AND TOTAL PARENTERAL NUTRITION. NEW MEDICATIONS OR MEDICATION CHANGES SHOULD BE WRITTEN ON A SEPARATE PHYSICIANS ORDER SHEET.

DO NOT USE THE FOLLOWING ABBREVIATIONS:

Ug (use ‘mcg’) U (use ‘Unit’) IU (use ‘International units’) QD, QOD (use ‘daily’ or ‘every other day’)

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