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Health Status Questionnaire

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  • If you have diabetes, please provide your history of diabetes, latest A1C count and a description of your treatment
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  • Please give us a brief description of your blood disorder(s)
  • Please give us a brief description of your autoimmune disorder(s)
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  • Please tell us the type(s) of cancer, when you were diagnosed, and what your treatment has been.
  • Please briefly describe any other health issues you have that have not been covered in these questions
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  • How much caffeine do you consume and how often?
  • How much alcohol do you consume and how often? Example: 1 glass of wine per day
  • Please describe your tobacco habit. How many cigarettes (or cigars) do you smoke per day? How long have you been smoking?
  • If you have quit smoking, how long ago did you quit? What did your tobacco habit consist of (how many cigarettes or cigars per day for how long)?
  • What type of recreational drugs do you use? How often?
  • If you have struggled, or are currently struggling, with drug and/or alcohol abuse, please describe your history or current circumstances.
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  • If you checked "other food" please list the foods to which you are allergic
  • If you checked "medications" please list the medications to which you are allergic
  • Please check all that apply. You will be prompted to provide the dosages and frequency of prescription and over-the-counter medicines.
  • Please list all prescription medicine(s) you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
  • Please list all over-the-counter medicine(s) you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
  • Please list all supplements you are currently taking, including the dosage and frequency. If you do not recall the dosage and/or frequency, please say so.
  • Please check all that apply. If you choose "Previous surgeries," you will be prompted to list the procedures and their dates.
  • Please list your previous surgeries and the dates the procedures were performed.
  • Have you or any member of your family ever had a problem with anesthesia? If you answer "yes," you will be prompted to describe the problem(s).
  • Please describe your problem with anesthesia
  • Please tell us who in your family has had a problem with anesthesia, and describe the problem.

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  • Technology

    Utilizing the most technologically advanced equipment in the industry.

  • Our Physicians

    Our physicians are the premier orthopedic surgeons in SW Florida.

  • Questions?

    Read our FAQ section for the quickest answers to your questions.

  • Find Us

    Located in the heart of Naples, FL. Get directions from your location.

1879 Veterans Park Dr., Suite 1101 Naples, FL 34109 Office: 239.592.4955 Fax: 239.631.2960

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