General Information |
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First Name :: |
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Middle Name : |
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Last Name :: |
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Age :: |
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Date of Birth ::
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month/dd/yyyy |
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Marital Status:: | |
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E-mail:: |
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Phone :: |
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Address :: |
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City:: |
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| State :: |
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Country :: |
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Surgery request:: | |
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Date of surgery:: |
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How do you find about us?:: | |
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History of past illness |
| Have you had any previous surgery? |
yes
no |
| If 'yes ' please list surgeries |
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| Have you ever had any of the following: |
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Congential abnormalities ::
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Cancer :: |
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Prior Surgery :: |
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Significant hospitalization :: |
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Other serious ilness :: |
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Chickenpox :: |
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Tuberculosis :: |
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Stroke :: |
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Diabetes :: |
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Rheumatic fever or heart disease :: |
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| If you have answered yes to any of the above questions, please list the details below if appropriate: |
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Medications currently taken |
Please list doses and the interval taken, name of medication,
dose and number of times taken per day |
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Family history |
| Please indicate if any blood relative had any of the following conditions: |
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Cancer |
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Peptic Ulcer Disease |
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Colon polyp(s) |
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Colon diverticulosis |
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Colitis or Crohn's Disease |
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Pancreas disorder |
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Liver disease |
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Diabetes |
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Heart trouble |
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Stroke |
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Convulsions or seizures |
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Bleeding tendency |
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Arthritis |
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Anemia |
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Kidney disorder |
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Tuberculosis |
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Please complete the following information regarding your close relatives:
if deceased, please enter age at death and cause of death |
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Father |
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Mother |
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| Please enter any other important family history not listed above: |
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Social / personal history |
| Please indicate if any blood relative had any of the following conditions: |
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Drinking alcohol |
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Smoking |
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Do you drink coffee? |
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Are you exposed to fumes, dust or solvents? |
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What is your job/ occupation? |
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Drugs recently taken - within the past six months |
| Mark all that are appropriate |
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Allergies and sensitivities |
| Please mark all that are appropriate |
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Penicillin
Sulfa drugs
| Other antibiotic
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Morphine
Codeine
Demerol
| Other narcotic
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Novocaine
| Other anesthetics
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Aspirin / Empirin
| Other analgesics
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Tetanus antitoxin
| Other serums
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Iodine or merthiolate
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Eggs
Milk
Shellfish
| Other foods
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Other drug or medication
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System review |
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Please provide the following general medical information: |
| | A: General |
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Height |
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Weight |
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BMI (if you know it) |
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Recent weight change |
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Good health in general |
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Fevers |
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Chills |
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| B: Gastroinstestinal
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Change in appetite |
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Trouble swallowing
(eg. food sticks in the throat) |
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Pain with swallowing |
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Regurgitation of food |
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Belching |
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Heartburn |
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Nausea |
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Peptic Ulcer Disease
(stomach or duodenum) |
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Vomiting food or blood |
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Surgery to the esophagus |
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Surgery to the stomach |
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Surgery to the small intestines |
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Surgery to the large intestines (colon) |
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Bloating |
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Abdominal pain |
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Pain after meals |
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Food intolerance |
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Gall bladder disease
(e.g. surgery or gallstone) |
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Liver disease |
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Jaundice |
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Hepatitis |
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Blood Transfusion |
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Pancreas Disease |
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Constipation |
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Diarrhea |
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Laxative use |
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Black colored bowel movements |
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Colitis |
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Crohn's Disease |
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Diverticulosis |
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Polyps |
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Recent change in bowel habits |
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Painful bowel movements |
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Blood in the stool |
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Mucus in the stool |
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Pus in the stool |
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Irregular bowel movements
(inability to control timing) |
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Hemorrhoids |
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Bowel movements in the late night |
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Anal pain or cramps |
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Anal itching |
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Anal fissures |
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Fistula |
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Enema use |
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| | C: Skin
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Skin Disease |
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Jaundice |
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Hives |
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Eczema |
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Rash |
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Frequent infection or boils |
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Abnormal Pigmentation |
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| | D: Respiratory
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URI (cold) presently |
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Spitting up blood |
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Chronic or frequent cough |
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Asthma |
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Wheezing |
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Difficulty breathing |
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Any trouble with lungs |
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Pleurisy |
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Pneumonia |
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| | E: Gynecological
mark here if not applicable
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Periods |
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Age started |
years |
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Duration |
days |
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Frequency | every
days |
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Pregnancies |
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Miscarriages |
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Date of first day of last period |
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Endometriosis |
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| | F: Neck
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Stiffness |
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Thyroid trouble |
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Enlarged glands |
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| | G: Head-Eyes-ears-nose-throat
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Eye disease or injury |
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Do you wear glasses? |
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Do you wear contacts? |
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Double vision |
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Headaches |
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Glaucoma |
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Itchy eyes or nose |
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Sneezing or runny nose |
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Nosebleeds |
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Chronic sinus trouble |
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Ear disease |
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Impaired hearing |
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Dizziness |
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Transient episodes of unconsciousness |
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| | H: Cardiovascular
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Chest pain or angina pectoris |
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Shortness of breath with walking |
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Shortness of breath with lying down |
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Difficulty walking two blocks |
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Heart trouble or heart attacks |
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High blood pressure |
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Swelling of hands |
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Swelling of feet |
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Swelling of ankles |
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Awakening at night smothering |
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Heart murmur |
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Valvular heart disorder |
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| | I: Genitourinary
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Frequent urination |
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Loss of urine |
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Night time urination |
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Burning or painful urination |
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Blood in the urine |
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Kidney trouble |
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Kidney stones |
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| | J: Locomotor - mulculoskeletal
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Varicose veins |
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Weakness of muscles |
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Weakness of joints |
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Any difficulty walking |
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Claudication |
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(pain in calves/ buttocks on walking not relieved by rest) |
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Arthritis |
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Back pain |
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| | K: Neuro - Psychiatric
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Ever had psychiatric care? |
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Ever advised to see a psychiatrist? |
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Fainting spells |
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Convulsions |
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Paralysis |
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| | L: Hematologic
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Are you slow to heal after cuts? |
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Blood disease |
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Anemia |
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Iron deficiency |
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Iron overload |
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Phlebitis |
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Abnormal brusing |
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Abnormal bleeding |
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History of excessive bleeding (after tooth extraction or surgery) |
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Thalassemia |
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| | M: Hematologic
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Thyroid disease |
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Hormone therapy |
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Change in hat or glove size |
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Any change in hair growth |
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High cholesterol |
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High triglyceride |
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Dry skin |
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Hot intolerance |
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Cold intolerance |
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Diabetes |
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Psychological evaluation |
| Please provide the following information: |
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:: Required Information |
