Pre-Admission Testing Questionnaire

We at Gramercy Surgery Center, would like to take the hassle out of your hands and place them where they belong — with our Medical Director and the Anesthesia Department.

When your patient visits your office, ask him or her to fill out our Patient Evaluation/Triage questionnaire. It is simple to complete and will only take a few minutes. Send the completed questionnaire to us when you fax the booking form to 866.249.5146. Let us take care of the rest.

Our Medical Director will review the form within 24 hours and decide if the patient needs a call from our nursing staff. Our nurses will interview the patient and along with our medical director, they can decide if further work up is necessary. We will inform the patient and confirm via phone call, fax or email to your office on what is needed. Our Pre-Surgical Testing Coordinator will follow-up with you and the medical office.

By allowing us to make the decisions, we can save time for you and your patient, 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


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)