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Mission Statement
At Outpatient Surgical Center of Ponca City, we strive to make the patient’s experience positive – from scheduling the surgery through  postoperative follow up.
Our goal is to provide friendly, professional care in a clean, relaxed atmosphere, at an   affordable cost. We care about our patients and their families.
OUTPATIENT SURGICAL CENTER OF PONCA CITY
                      400 Fairview, Suite 50       Ponca City, OK  74601     (580) 762-0695 
Pre-Anesthesia Assessment Questionnaire
(PLEASE COMPLETE FORM AS COMPLETELY AS POSSIBLE)
Dont want to fill it out online - click here for printable form
Email Address:  
Patient's Name:
Birthday
Please answer the following questions by placing a mark in the correct box.  Please select each item if you have been treated for the illness in the past or are currently being treated for the illness.  Have you had the following?
Heart Problems Smoking (if yes)
Heart Attack

How many/much per day?

Chest Pain Hiatal Hernia
Lung Disease (if yes) Stomach Problems

Asthma

 Diabetes
Headaches
Seizures
Numbness in any body part Mental Illness
Muscle Weakness Alcoholism - Drug Addiction
Stroke Sleep Apnea
Back Injuries Arthritis
Females: Could you be pregnant?

List all previous surgical procedures you have had (include office procedures)

Have you ever had problems with Anesthesia? If so please describe:

Have you or any family members had Malignant Hyperthermia?

List all medications and their dosages that you are currently taking, include inhalers, insulin, oxygen and vitamins or herbal therapy. Next to each medication indicate the dosage (mg, units, etc.) and how often you take it.

List any medication reactions/Allergies:

Please select if you have any of the following:
Capped Teeth Partial Plates Contact Lens
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