Orthopedics

Location Information

How may we help you?

How may we help you?

Joint Replacement Patient Information Form

Blanchard Valley Hospital
1900 S. Main St.
Findlay, OH 45840

Bluffton Hospital
139 Garau St.
Bluffton, OH 45817

All fields are required.

First Name:  *Last Name:  *Date of Birth:  *Email:  *Family Physician:  *Family Physician City  *Family Physician Phone:  *Preferred Pharmacy:  *Preferred Pharmacy City:  *Preferred Pharmacy Phone:  *Page Break 

Health Background

Height:  *Weight:  *Are You: Surgeon:  *Procedure:  *Do you have any of the following? 




















Have you had cancer or radiation?  *If yes, what type? Are you being treated for diabetes?  *If yes, what type of treatment? 

Kidney Issue: Previous anesthesia issues: Last Tetanus Shot:  *Date of Last Tetanus Shot: Prescription and over-the-counter  *Page Break 

Medications

Medication 1: Dosage: Frequency: Medication 2: Dosage: Frequency: Medication 3: Dosage: Frequency: Medication 4: Dosage: Frequency: Medication 5: Dosage: Frequency: Medication 6: Dosage: Frequency: Medication 7: Dosage: Frequency: Medication 8: Dosage: Frequency: Medication 9: Dosage: Frequency: Medication 10: Dosage: Frequency: Medication: Dosage: Frequency: Medication 12: Dosage: Dosage: Frequency: Medication 13 Dosage: Frequency: Medication: Dosage: Frequency: Medication 15: Dosage: Frequency: Medication 16: Dosage: Frequency: Medication 17: Dosage: Frequency: Medication 18: Dosage: Frequency: Medication 19: Dosage Frequency: Medication 20: Dosage: Frequency: Page Break 

Allergies

Do you have any allergies to medications, metals, latex, food, etc.?  *Item 1: Reaction: Item 2: Reaction: Item 3: Reaction: Item 4: Reaction: Item 5: Reaction: Item 6: Reaction: 

Surgical History

Have you had any surgeries?  *If yes, please list all surgeries and the year they occurred. 

Social History

Smoker? 


If yes, how many packs per day? If yes, how long? Illegal Drug Use? If yes, how much? Alcohol Use? If yes, how much? Family history of: (check all that apply) 



Does your family physician permit you to take 

Have you had any of the following tests recently? 

If so, where and when?