Pre-Admission Questionnaire

Hamilton Medical Center
Dalton, Georgia
Surgical Services
Pre-Admission Questionnaire


Please enter the following information:
All information provided is protected by HIPAA (Privacy Rule). This information stays confidential but is necessary
for your treatment (ex: drug interactions). To find out more go to www.hhs.gov and/or www.hamiltonhealth.com
   

Please check yes/no if you currently or in the past have had any of the following conditions:
NEURO YES NO


          



          
          


          







          

          

          

          



          
          



AIRWAY/CHEST YES NO


          
          


          
          


          
          




          
          


          
          


          
          




          

          

          
          
          
          

GASTROINTESTINAL/RENAL YES NO


          



          
          



INFECTIOUS DISEASE YES NO










          
          
          
          


          
          
          
          
          
          

CARDIAC YES NO






          
          


          
          


          
          


          
          


          
          


          
          
          
          


          
          
          
          




          
          


          
          


          
          


          
          


          
          


          

          
          


          
          














          
          

ENDOCRINE YES NO





OB/GYN YES NO





IMPORTANT – List ALL medications (prescription and over-the-counter medications, herbal remedies, dietary supplements, vitamins, creams/ointments, etc.) that you are currently taking/using.

If you DO NOT take any of the items listed above, please check this box.   

This questionnaire is considered incomplete if this section is left blank.

Medication Name Dosage/Strength How many times a day do you take it? What do you take it for?