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Onslow Surgical Clinic

Pre-Operative Patient Questionnaire

First Name

Last Name

Phone

Email

If yes, name of physician:

Current Blood Pressure

If yes, name of medication:

If yes, name of physician:

If yes, days of week received?

Most recent HbA1c:

If yes, name of medication:

If yes, name of medication:

If yes, name of physician:

Describe:

If yes, name of physician:

If yes, name of prescribing physician:

Type of reaction:

Type of reaction: