2730 Pierce Street • Sioux City, Iowa • Phone 712-294-7777

Home       Medical Staff       FAQ       Success Stories       Insurance       Contact

If you would like to visit with a nurse to pre-register, please call 294-7777. When you call to register, please be prepared to supply the following information. For your convenience, you may also complete the online registration form below.

Patient Name:
Birth Date:
Social Security #:
Address:
City, State, Zip:
Home Phone Number:
Work Phone:
Cell Phone:
Email Address:
Employer Name:
Employer Address:
Employer Phone:
Guarantor:
Insured's Social Security # (if different than patient's):
Insured's Birth Date:
Insurance Company:
Policy Number:
Group Number:
Insurance Company's Address & Telephone #:
Date of Procedure:
Surgeon:
Procedure:
Gender:	Male Female
Height (feet & inches):
Allergies/reactions to Medication:	Yes No
Food Allergies:	Yes No
Latex Allergies:	Yes No
Other Allergies:	Yes No
List All Allergies:
Patient Health History. Does the patient have or ever had:	Heart Problems (congestive heart failure, chest pain, murmur, irregular heart beat, heart attack, rheumatic fever, ankle swelling) High or Low Blood Pressure Lung Problems (asthma, emphysema, COPD, tuberculosis) Sleep Disorders, Sleep Apnea, Snoring Neurologic Problems (seizure, stroke) Bone or Joint Problems Psychological or Behavioral Disorders Cancer Chronic Infections, MRSA, VRE, HIV Implanted Devices - pacemaker, defibrillator, implanted IV, shunt Sexual Problems, STD Disease Diabetes Hypoglycemia (low blood sugar) Kidney/Bladder/Prostate Problems Thyroid Problems Liver Problems (hepatitis, jaundice) Acid reflux, esophageal disease, stomach or bowel problems Bleeding Problems, or take blood thinners, history of blood clot Smoking, tobacco use, alcohol, street drugs Wear contact lenses ENT Problems (ear, nose, throat) Hearing aids, dentures
Do you have any special communication needs? If yes, please specify:	Vision Hearing Language Speech
Do you have any physical limitations? If yes, please be specific:
Any illness/infection in past week prior to surgery? If yes, please describe:
Do you take any medications?	Yes No
List all meds including aspirin, Advil, Motrin, Ibuprofen, other over-the-counter meds and dosages:
Do you take any vitamins, herbal or alternative medications? If yes, please list:
Have you ever had surgery before? If yes, please list past surgeries:
Have you or any family member had problems with anesthesia? If yes, please describe who and the reaction:
For Pediatric Patients. Type of feeding:	Breast Bottle Sippy Cup Table Foods
For Pediatric Patients. Birth History:	premature full term
Birth History - # of weeks:
Birth History - Stay in INCU?
Birth History - On ventilator or oxygen? Number of days?
Genetic Disorder/Birth Defects? If yes, please describe:
Behavioral Disorders/Problems? If yes, please describe:
Child lives with:	parent foster parent group home grandparent