Heart Surgery Form

HeartForms- Heart Surgery

HeartForms Home / Blank Heart Surgery Form / Heart Cath Form / KCCQ-12 / NYHA Classification for Heart Failure / Review of Systems
Name of Practice:
First name:
Last name:




The hospital/ clinic surgery to be performed at:
Hospital/ Clinic Surgery Site Phone number:
Your office/ clinic phone number:

Do you take any of the following:












Click "Try it" to display the value of each element in the form.

Medications: Some of your medications will need to be stopped prior to surgery, including blood thinners, certain blood pressure medicines, and certain diabetic medications. Prior to surgery:

Day of Surgery


- Do NOT eat or drink anything after midnight before surgery
- Do NOT take any of your regular medications the morning of surgery unless instructed to do so by anesthesia at your pre-admission appointment.
- Your family will be shown to the surgery waiting room and will receive periodic updates.
- The surgeon will talk with you or your family after surgery.
- If you have questions regarding visitation during hospitalization please call:


Call the office at

-any questions regarding surgery -you develop an infection that requires antibiotics of any kind
-there is any change in your condition -you develop a fever, cold, or flu symptoms
-are prescribed new medications

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