Tubal Reversal Experts
Medical and Anesthesia History

Please complete this form and fax it to (727) 796-8764.  This medical and anesthesia history form must be submitted to us via facsimile. Once you complete the form click your web browsers print button and fax this form to us.

Please call us at (866) 882-2573 if you have any questions.

Please be sure the form is complete and accurate. This information is to ensure your health and safety when Dr. Edward Zbella or Dr. Mark Sanchez performs your tubal reversal surgery. Providing inaccurate information will result in your surgery being delayed or cancelled.

Please send forms with medical records.
Your name:
Date of surgery:
Height: feet inches
Weight:


How may we contact you?
Email:
Work Phone: - -
Home Phone: - -
Cell Phone: - -


The adult who will accompany me on the day of surgery is:

Name:
Relationship:
Cell phone: - -


All the questions below require an answer:
 1.  Have you ever been "put to sleep" or received anesthesia? Yes No
 2.  Have you ever had a problem due to anesthesia? Yes No
 3.  Has any family member had a problem with anesthesia? Yes No
 4 . Have you ever been hospitalized for non-surgical problems? Yes No
 5.  Do you take any prescription medications? Yes No
 6.  Do you take herbal medications or supplements? Yes No
 7.  Have you ever received a steroid or cortisone medication? Yes No
 8.  Are you allergic to or had an adverse reaction to medicine? Yes No
 9.  Have you ever had a problem with your lungs? Yes No
10. Do you currently have a respiratory infection (a "cold")? Yes No
11. Have you ever had heart or blood pressure problems? Yes No
12. Have you ever had hepatitis or a problem with your liver? Yes No
13. Have you ever had a problem with your kidneys? Yes No
14. Have you ever had thyroid disease? Yes No
15. Do you have diabetes? Yes No
16. Have you ever had a problem with seizures or epilepsy? Yes No
17. Do you have any eye disease (such as glaucoma)? Yes No
18. Do you have any loose, false, capped or chipped teeth? Yes No
19. Do you have any type of back or neck problems? Yes No
20. Do you have any muscle weakness? Yes No
21. Have you ever received a blood transfusion? Yes No
22. Have you ever had a blood transfusion reaction? Yes No

23. Have you ever seen a nerve specialist?

 Yes No
24. Do you smoke? Yes No
25. Do you use alcohol? Yes No
26. Have you ever had a history of drug abuse? Yes No


Please elaborate on each answer marked "Yes", identifying each affirmative answer
with the number corresponding to the specific question:


I have answered the above questions accurately and have provided details regarding any questions answered yes.