Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.

Transcription

1 GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA Phone: (610) PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST AT OUR OFFICE; PLEASE PRINT. Patient Name: Last First MI Page 1 of 5 Date: Date of Birth Age CHIEF COMPLAINT(S)(reason for medical visit): Name/Address of Physician who requested you to consult General Surgical Associates: Reason for the consult: Name of Family Physician and address: Other Physician(s) to whom you prefer reports to be sent Please list all Allergies (Medicine, Food, Other) 1) 2) 3 4) 5) 6 Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency. Medication Dosage Frequency Medication Dosage Frequency PAST MEDICAL HISTORY Heart Disease Yes No Describe: Year: Pulmonary Disease Yes No Describe: Year: Stomach Disease Yes No Describe: Year: Bowel Disease Yes No Describe: Year: Neurological Disease Yes No Describe: Year: Muscular/Skeletal Disease Yes No Describe: Year: History of MRSA (Methicillin-resistant Staphyloccus aureus) Yes No Year Other: 1

2 SOCIAL/HEALTH MAINTENANCE HISTORY Do you use Tobacco Products? Do you drink caffeine products? Do you drink alcoholic beverages? Yes No How Much? How Often? How Many Years? Quit Date(s) Do you exercise? Occupation: Retired? (yes or no) Year Marital Status: (please check one) Single Married Divorced Widowed Please list all X-Rays and other tests you have had: X-Rays and Other Tests Date Location Have you ever had a blood transfusion? Yes No Reaction: Have you ever had anesthesia? Yes No Reaction: FAMILY HISTORY Please complete for all your brothers, sisters, and parents that are applicable. Family Member Diabetes Y = Yes N = No U = Not Known Heart Disease High Blood Pressure Stroke Bleeding Tendencies Cancer Type of Cancer Deceased Age at Death 2

3 SURGICAL HISTORY Please check all that apply. Cholecystectomy Appendectomy Thyroidectomy Hernia Repair Hysterectomy Please list all previous hospitalizations, surgeries, and procedures. Hospitalizations, Surgeries, Procedures, Injuries Date Location Physician REVIEW OF SYSTEMS: (please check all that apply or choose none) General: Fever Anorexia Weight loss Gastrointestinal: Abdominal pain Nausea Vomiting Diarrhea Constipation Change in bowel habits Difficulty Swallowing Dark Stools Bloody Stools Jaundice Gas/bloating Indigestion/heartburn\ Breast: Left breast lump Right breast lump Nipple discharge Bloody discharge from nipple Breast pain Abnormal mammogram Breast enlargement Cardiovascular: Chest pains Palpitations Syncope Peripheral edema 3

4 Respiratory: Cough Shortness of breath Coughing up blood Wheezing Pleuritic chest pain Vascular: Varicose veins Leg swelling Leg redness Pain in legs with walking Resting leg pain Pain at night in legs Blue toe(s) Leg Coolness Genitourinary Vaginal discharge Incontinence Painful urination Blood in Urine Abnormal vaginal bleeding Pelvic pain Pregnancy Wound Wound redness Wound discharge Wound pain Opening of wound Purulent discharge Bleeding from wound Dermatology Suspicious lesions New skin lesions Changing mole(s) Rash Itching History of skin cancer Neurological Paralysis Numbness Seizures Frequent headaches Psychiatric Depression Anxiety Memory loss Suicidal ideation Suicidal thoughts Hallucinations Paranoia Phobia Confusion Endocrine Cold intolerance Heat intolerance Excessive thirst Increased appetite Excessive Urination Unusual Weight change 4

5 Hematology Abnormal bleeding Bleeding Enlarged lymph nodes Musculoskeletal: Back pain Sciatica Arthritis Other: Stoma redness Pain around stoma Discharge from stoma Pain from venous catheter Redness at vascular access site Purulent drainage from vascular access site Please describe any additional problems/concerns which you think the Physician should be made aware. 5