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Gastroenterology Consultants of South Jersey
Amherst Commons, Building A, Suite 2
693 Main Street, Lumberton, New Jersey
Telephone: (609) 265-1700    Visit us Online:

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Ambulatory Surgical Center - Patient Check List

Patient : Please answer ALL questions listed by checking yes or no.



1. In the last six months have you had a heart attack, bypass surgery, or angioplasty?


2. At home, are you dependent upon OXYGEN ?


3. Do you have a history of any type of bleeding disorder?


4. Do you have an artificial heart valve or any history of Endocarditis?


5. Are you on Coumadin, Aspirin, or any Arthritis medicine?


6. Do you receive antibiotics before you have dental work?


7. Are you a diabetic and taking any medication for it?


8. Are you allergic to Latex?


9. Are you allergic to eggs, soybeans, or sulfites?


10. Are you pregnant or nursing ?



11. Do you take any vitamins or herbal supplements?


12. Have you ever had any problems with Anesthesia?



13. Do you have a history of sleep apnea?



Patient's Signature: ______________________________________________________________

Date: _______ / ______ / 20____

Doctor or Nurse's Signature: ________________________________________________________

*ANY STARRED ITEM that the Patient answers "YES" to is to be referred to Anesthesia at checkout for review.

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