Download Past Medical History

PAST MEDICAL/SURGICAL HISTORY
Please indicate if positive only
Past Medical History:
Past Surgical History:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Back Surgery
Hip Replacement
o RT o LT
Knee Replacement
o RT o LT
Rotator Cuff Repair
o RT o LT
Knee Arthroscopy
o RT o LT
Shoulder Arthroscopy o RT o LT
Elbow Arthroscopy
o RT o LT
Tonsillectomy/Adenoidectomy
Thyroid Surgery
Appendectomy
Gallbladder Surgery
Hernia Repair
Cataract Surgery
Cardiac Pacemaker
Hysterectomy
Cesarean Section
Prostate Surgery
**Please list further surgeries if not indicated.
Social History:
N
N
N
Y Alcohol Use
Y Smoking
Y Drug Use
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Family History:
N
N
N
N
Marital Status: o Single o Married o Widowed
MEDICATIONS:
Taking Blood Thinners
Hypertension (High Blood Pressure)
Coronary Artery Disease
Congestive Heart Failure
Asthma
COPD (Chronic Bronchitis)
Diabetes Mellitus
HIV Infection
Cancer
Rheumatoid Arthritis
Esophageal Reflux
Deep Vein Thrombosis/Thrombophlebitis
Osteoporosis
Gout
Prostate Disorder
Renal Disorder (Kidney Disease)
Thyroid Disease
Sleep Apnea
Using CPAP
Y
Y
Y
Y
Cancer
Heart Disease
Hypertension (High Blood Pressure)
Osteoarthritis
Height:_________ Weight:_________
ALLERGIES TO MEDICATIONS:
Patient Name (please print)
Patient/Guardian SignatureDate
REVIEW OF SYSTEMS
Please indicate if positive only
Systemic Symptoms:
o Weight Change
o Chills
o Fever
Hematological Symptoms:
o Easy Bleeding
o Easy Bruising Tendency
Psychological Symptoms:
o Anxiety
o Depression
Gastrointestinal Symptoms:
o Difficulty Swallowing (dysphagia)
o Heartburn
o Nausea
o Vomiting
o Blood in Stool
Skin Symptoms:
o Rashes
o Skin Lesions
Pulmonary Symptoms:
o Shortness of Breath
o Cough
o Wheezing
HEENT
o Headache
o Nosebleeds (epistaxis)
Neurological Symptoms:
o Dizziness
o Seizure
o Stroke/TIA
Cardiology Symptoms:
o Chest Pain or Discomfort
o Fast Heart Rate
o Palpitations
Endocrine Symptoms:
o Excessive Sweating
o Excessive Thirst (polydypsia)
Genitourinary Symptoms:
o Hematuria
o Dysuria
o Increased Urinary Frequency