Anterior Hip

Patient Information SheetThis information sheet is very valuable to the patient care team at the Rose Institute for Joint Replacement.Please answer the questions truthfully. It should be completed prior to your next physician appointment.Your patient care team will be referring to it regularly.Patient’s Name: Height: Weight:ALLERGIESDo you HAVE allergies to:LatexMedicationsFoodsEnvironmentsContrast MediaOtherapple Yes apple Noapple Yes apple Noapple Yes apple Noapple Yes apple Noapple Yes apple No__________If answered YES to the above, list names of known allergens:CURRENT MEDICATION LIST*List ALL prescriptions, herbals, vitamins, and over-the-counter medications*Name(i.e. Lasix)Dose(i.e. 20mg)Route(i.e. oral)Frequency(i.e. twice a day)Time & date last dose takenbefore surgeryIMMUNIZATIONSHave you had the Pnuemovax vaccine?Have you had a Flu shot? (If yes: when________)Other:apple Yes apple Noapple Yes apple No