History & Physical | Flaheartvascular.com

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Florida Heart & Vascular Surgery Center

Medical History

First name*

Last name*

Email*

Date of upcoming Service

Month

Day

Year

Have you completed the required Lab Work ordered by the Surgeon prior to your upcoming procedure

Yes

Lab Work Not Ordered

Present Illness/ Medical History*

Please type NA if no present medical conditions

Allergies & Allergy Reactions*

Please type NKDA id no medication allergies to report

Any Hospital admissions in the last 7 days*

Yes

If Yes, Please provide reason for hospital admission and the date admitted.

Do you require any special accommodation on the date of your procedure?*

Yes

If Yes, Please provide a detailed list of accommodation needed

Have you had any surgeries in the last 7 days un-related to your upcoming procedure. E.g. Back Surgery, Colonoscopy etc.*

Yes

If yes, please provide name of surgery and date performed

In the past 14 days, have you tested positive for the Flu Virus or COVID virus?*

Yes

In the past 7 days, have you has the following symptoms: Fever, coughing, swollen lymph nodes or congestion?*

Yes

Are you currently taking antibiotics for any recent infections unrelated to your upcoming procedures.*

Yes

If yes, what is the name of the antibiotics you are currently taking, reason you are taking antibiotics and how many days left to complete dose?

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