Download PATIENT`S NAME:

HISTORY AND PHYSICAL
PATIENT’S NAME: __________________________________________________
DATE:____________
AGE: _______ HEIGHT: ____________ WEIGHT: ____________ NUMBER OF CHILDREN: _____
Part I HISTORY
The following questions are to be filled out by the patient. Check box YES or NO. Any positive response will be
discussed with you by your doctor.
LUNGS
Born with any lung disease
Cough or cold (at present)
Bronchitis
Asthma
Emphysema
Smoke
packs of cigarettes
per day for the past
years.
HEART
Born with any heart disease
Heart murmur
High blood pressure
Skipped heart beats
Chest pain
Hardening of the arteries
Heart failure
Heart attack
Rheumatic fever
BLOOD
Do bruise or bleed easily
Abnormal bleeding (of any kind)
in family
Sickle cell trait/disease
Other blood cell disease
Prolonged bleeding with
tooth extraction
YES
□
□
□
□
□
NO
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
NERVOUS SYSTEM
Born with abnormality of
nervous system
Brain disease
Spinal cord disease
Nerve disease
Epilepsy
Stroke
YES
NO
□
□
□
□
□
□
□
□
□
□
□
□
ENDOCRINE
Diabetes (blood sugar)
Thyroid disorder
□
□
□
□
EYE
Glaucoma
Contact lenses
□
□
□
□
STOMACH, BOWEL, GALL BLADDER
Any disease of?
□
AIRWAY
Problems opening mouth wide
Problems turning head in
any direction
□
□
□
□
□
□
REPRODUCTIVE
Female: Are you pregnant?
Planning preg. preoperatively?
Have you breast fed in last 3 mos?
□
□
□
□
□
□
□
□
□
□
□
□
□
□
MUSCULOSKELETAL
Any injury or damage to:
Joints
Tendons
Nerves
□
□
□
□
□
□
KIDNEY
Born with kidney disease
Kidney infections/disease
Kidney stones
□
□
□
□
□
□
Do you have any past or present health problems not
indicated above? If yes, please describe: _____________
_____________________________________________
_____________________________________________
Any history of mental illness?
□
□
Do any diseases run in your family? If so, name them: __
_____________________________________________
_____________________________________________
_____________________________________________
□
□
□
□
□
□
□
□
□
LIVER
Drink alcoholic beverages
Hepatitis
Jaundice
Other liver disease
YOU MUST COMPLETE THE BACK OF THIS
FORM!
HISTORY AND PHYSICAL
SURGICAL HISTORY: List previous operations and
approximate dates: ______________________________
______________________________________________
______________________________________________
_____________________________________________
Who is your primary care physician? _______________
_____________________________________________
City: _________________________________________
Phone number: _________________________________
______________________________________________
Have you ever had complications
after surgery?
Bleeding or blood clot
Infection
YES
□
□
NO
□
□
Other: ________________________________________
______________________________________________
______________________________________________
ANESTHETIC HISTORY
Date of last general anesthetic: _____________________
Any problems resulting from any local or general
anesthetic ever administered to you? □
□
Nausea and/or vomiting?
□
□
Any family members with problems
related to anesthesia?
□
□
If you answered yes, please explain: _________________
______________________________________________
______________________________________________
DRUG ALLERGIES (List): ______________________
What kind of reaction? ___________________________
LIST ALL PRESENT MEDICATIONS (By name and
the reason for taking them). Especially important are:
Coritsone, hormones or birth control pills, cold
medications, aspirin or aspirin-containing medications,
tranquilizers, sedatives, antidepressants, blood thinners
(anticoagulants), heart medications, and water pills
(diuretics).
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Any history of Arthritis? _________________________
If so, type of Arthritis: ___________________________
If you are taking Arthritis medication, please list: ______
_____________________________________________
_____________________________________________
Name of the physician treating Arthritis:
_____________________________________________
List any vitamins and/or herbal supplements you are
presently taking:
_____________________________________________
_____________________________________________
Patient’s Signature____________________________________________ Date: _________________________________