|
Voided just prior to check in?
|
|
|
Time last eaten
|
Time last drank
|
|
|
|
|
Safe transport home
|
Phone number
|
|
Relationship
|
|
|
|
|
|
Medications taken prior to appointment
|
|
|
|
|
|
Uterus owners LMP
|
Any chance of being pregnant?
|
|
|
|
|
Blood Pressure
/
|
Heart Rate
|
|
Respirations
|
Oxygen Saturation
|
|
|
|
|
Pre Journey Medications
|
|
|
Snoring / sleep apnea?
|
CPAP?
|
|
|
|
|
Time of administration
|
Playlist name
|
|
|
|
|
Oxygen Saturation 30 minutes post
|
Heart rate 30 minutes post
|
|
Oxygen Saturation 60 minutes post
|
Heart rate 60 minutes post
|
|
|
|
|
Time of emergence
|
Discharge form provided to patient?
|
