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Template: Medical Intake
Pre-Surgery Assessment Form
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Assess readiness for surgery and collect necessary information.
This is a preview of the template. Click here to use it.
Full Name
*
Date of Birth
*
Do you have any allergies to medications?
*
Have you experienced any of the following in the past 6 months?
*
Chest pain
Shortness of breath
Palpitations
Recent illness
None
Current Medications
*
Do you have a history of any previous surgeries?
Signature
*
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