Get Surgical Pre-testing Patient Questionnaire Form - Unity Health System - Unityhealth

This guide provides a clear and supportive overview of how to complete the Surgical Pre-testing Patient Questionnaire Form required by Unity Health System. Follow the step-by-step instructions to ensure your form is filled out accurately and completely.

Follow the steps to successfully complete the Surgical Pre-testing Patient Questionnaire Form

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering your phone numbers in the designated fields for home and cell. Include your name and work number in the provided spaces.
3. Specify the procedure you are having done in the corresponding field.
4. Indicate the operative side by checking the appropriate box for either 'Right' or 'Left'.
5. Provide the initials of the pretesting staff who will verify the procedure.
6. Answer whether you have had any serious illnesses or hospitalizations within the past year and provide details if applicable.
7. List any previous surgeries along with their dates in the designated space.
8. Indicate whether you currently receive or have received home care services in the last year by checking 'Yes' or 'No'.
9. If applicable, specify which agency provided home care services.
10. Go through the health questions related to various systems, such as eyes, heart, lungs, etc. Check all boxes that apply to you and provide additional information in the text fields where necessary.
11. For each health issue you check, provide the name of the corresponding specialist (e.g., heart doctor, lung doctor) and any relevant testing dates.
12. Complete the social habits section by marking any that apply, providing details about alcohol consumption, smoking status, and drug use.
13. Indicate your pregnancy status if applicable.
14. Fill in the details of your primary care physician and the date of your last visit, along with reasons for the visit.
15. Finally, sign the form and date it in the designated signature field.
16. Review your form for any missing information or errors, then save your changes, download, print, or share the form as needed.

Complete your Surgical Pre-testing Patient Questionnaire Form online today.