PRE-OPERATIVE PATIENT QUESTIONNAIRE
If you complete this questionnaire at home, fax form to 1-866-298-5563. Failure to fill out this form correctly may delay your surgery. DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: ... PRE-OPERATIVE PATIENT QUESTIONNAIRE (continued) DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:If yes please check box Chest pain, heart attack ... ................
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