Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download form - Western Surgical Group.
Document related concepts
no text concepts found
Transcript
*Patient Health History* Name: ______________________________________ Sex: ________ Age: _________ Referring Physician: __________________________________________D.O.B.________ Reason for Visit: __________________________________________________________ PAST MEDICAL HISTORY: Check all that apply ____Anesthesia Problem ____Emphysema ____Irritable Bowel Syndrome ____Angina ____GERD/Acid Reflux ____Kidney Disease ____Arthritis ____Glaucoma ____Liver Disease ____Asthma ____Heart Attack ____Migraines ____Back Problem ____Heart Disease (Type) ____Osteoporosis ____Bleeding Problem ____Hearth Rhythm Problem ____Seizures ____Blood Clots ____Hepatitis ____Sleep Apnea ____Depression ____High Blood Pressure ____Stroke ____Diabetes (Type) ____High Cholesterol ____Thyroid Disease ____Easy Bleeding ____Immune System ____Cancer (Type)_______________________________________________________ ____Other (Be Specific) __________________________________________________ GYNECOLOGIC HISTORY: Number of Pregnancies_____ Number of Live Births ______ Abortions_____ Age at 1st Pregnancy_____ Age of 1st Menstrual Cycle_____ Age of Menopause_____ Have you ever taken Birth Control Pills or Hormone Replacement Treatment? Yes ______ No______ If so, what is the age you started:_______ age stopped: ________ BREAST FEEDING HISTORY: Have you ever breast fed your children? Yes___ No ___ How many children have you breast fed? _____ For how long? ____ PAST SURGICAL HISTORY: Please list any surgical procedures you have had including the year it was performed. PROCEDURE YEAR ___________________________________________________ _______________ ___________________________________________________ _______________ ___________________________________________________ _______________ ___________________________________________________ _______________ ___________________________________________________ _______________ ___________________________________________________ _______________ ___________________________________________________ _______________ MEDICATIONS: List all current medications you are taking and the dosages. MEDICATION DOSE FREQUENCY FOR WHAT CONDITION ______________ ___________ ___________ __________________ ______________ ___________ ___________ __________________ ______________ ___________ ___________ __________________ ______________ ___________ ___________ __________________ ______________ ___________ ___________ __________________ Have you had a Flu vaccine within the last year? Yes No Have you had a Pneumonia vaccine? Yes No Date ___/___/___ Date ____/____/_____ Are you up to date on immunizations (pediatric patients)? Yes No ALLERGIES: Please list any allergies you have, including allergies to chemicals and foods. Type of Reaction ______________________________ ____________________________________ ______________________________ ____________________________________ FAMILY MEDICAL HISTORY: Circle all that apply, list the affected relative on the line below. ***************Please indicate Maternal or Paternal Relative ******************** Anesthesia Problem NO YES Affected Relative _______________________________ Arthritis NO YES Affected Relative _______________________________ Asthma NO YES Affected Relative _______________________________ Bleeding Disorder NO YES Affected Relative _______________________________ Breast Cancer NO YES Affected Relative _______________________________ Colo-Rectal Cancer NO YES Affected Relative _______________________________ Diabetes NO YES Affected Relative _______________________________ Esophageal Cancer NO YES Affected Relative _______________________________ Heart Attack NO YES Affected Relative _______________________________ Heart Disease NO YES Affected Relative _______________________________ High Blood Pressure NO YES Affected Relative _______________________________ High Cholesterol NO YES Affected Relative _______________________________ Lung Cancer NO YES Affected Relative _______________________________ Melanoma NO YES Affected Relative _______________________________ Obesity NO YES Affected Relative _______________________________ Pancreatic Cancer NO YES Affected Relative _______________________________ Renal Disease NO YES Affected Relative _______________________________ Seizures NO YES Affected Relative _______________________________ Stroke NO YES Affected Relative _______________________________ Thyroid Cancer NO YES Affected Relative _______________________________ Thyroid Disease NO YES Affected Relative _______________________________ Affected Relative _______________________________ Other Cancer Type:_______________________ SOCIAL HISTORY: Single___ Married ___ Divorced___ Widowed___ Partnered___ Occupation________________________________________________________________ Alcohol Use ___ No Yes___ Former___ Amount Per Day____ Start Age ___ Stop Age___ Drug Use ___No Yes___ Type _______________ Former___ Start Age ___ Stop Age___ Tobacco Use ___ No Yes___ Former___ Amount Per Day ____ Start Age___ Stop Age___
