Medical History Form | UnityPoint Health - Sioux City, Iowa

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Medical History Form

Thank you for choosing UnityPoint Health - St. Luke's in Sioux City, IA. 

Please complete the following the Medical History form in addition to the actual pre-registration form in order to complete your online registration for surgery or digestive health (GI) procedures at St. Luke's. If something doesn't apply and it is a required field please place "NA" in the field. When complete, please click "Submit."

To ensure your registration has been completed upon your arrival, please pre-register no later than 48 hours prior to the date of service. Thank you.




Patient Information


Marital Status
Gender
Race
Translation/Interpreter Services Needed?

Address


Employment Status (if applicable)

Emergency Contact Information



Medical History


Do you have a known sensitivity to products containing latex (e.g. rubber gloves, balloons, condoms)? *
Have you or any family member (e.g. parent, sibling, aunt, uncle, cousin) ever had a high fever (hyperthermia) during anesthetic? *
Have you or any blood relative (e.g. parent, sibling, aunt, uncle, cousin) ever had a high fever (hyperthermia) during an anesthetic, which resulted in a longer hospital stay? *
Females only: Are you or could you be pregnant?
Have you ever been treated for a heart attack, chest pain, or heart condition? *
Are you able to breathe when you lie flat? *
Do you sleep in a bed or a chair? *
Can you do light work such as dusting, washing dishes or carrying out the trash? *
Do you have chest pain or shortness of breath when you climb stairs or walk up a hill? *
What is your maximal level of exertion? For example, do you participate in moderate recreational activities like yard work, walking 1/2 mile or sports? *