Pre-Admission Testing Questionnaire

Easy Steps to determine if Pre-Admission Testing is required:

  • Fill out the questionnaire online. Scroll down and click the PLUS sign to expand the questionnaire. It takes less than 5 minutes to complete and submit the form. 
  • Or you can download the Pre-Admission Testing Questionnaire at the bottom of this page and fax the completed questionnaire to 866.249.5146

Our Medical Director will review the questionnaire within 24 hours. Our nursing staff will contact you if our Medical Director requires additional information. 

By allowing us to make the decisions, we can save time for you, and create an easier and less stressful peri-operative experience.

Should you have any questions, please feel free to contact our Patient Admissions Department at 212.254.3570 Option #3 or MedicalClearances@GramercySurgery.com.

Pre-Admission Testing Questionnaire

Click on Form to download

 



Pre-Admission Testing Questionnaire



  • Part 1









  • Part 2



  • Part 3


  • If asked to perform the following activities, would you be able to do so?



  • Light Intensity Activities (< 3)


  • Moderate Intensity Activities (3 to 6)


  • Vigorous Intensity Activities (> 6)