SURGERY SPECIALTY PATIENT HEALTH HISTORY
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- Millicent Austin
- 6 years ago
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1 SURGERY SPECIALTY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To Foods? 2. Are you allergic to latex? 3. Are you allergic to iodine? Medications 1. Are you taking any pain medications YES NO If so, please list all: Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking rthwest Hospital & Medical Center University of Washington Physicians PAGE 1 OF 6
2 Social History Tobacco Use o o onevero oquito opassive Packs/day o0.25o o0.5o o1o o1.5o o2o o3o oooooo Years o0.5o 1o o2o o3o o4o o5o o10o o15o ooo o Quit O ooooo Enter Date Types ocigaretteso opipeo ocigarso osnuffo ochewo Alcohol Use o o oo Drinks/Week # Glass(es) of wine # Can(s) of beer # Shot(s) of liquor # Drink(s) with 0.5oz of alcohol Drug Use o o oo Types oamphetamines/metho oanabolic Steroidso Use/Week 1o o2o o3o o4o o5o o10o o15o oo o obenzodiazepineso ococaineo ohallucinogenso omarijuanao oopioidso oivo oinhaledo ointranasalo ooralo Other Are you currently working? o o oo What is or was your occupation? Specialty Medical History 1. Have you had any of the following (please check all that apply): Abnormal ECG Deep Vein Thrombosis Pacemaker or Implanted Defibrillator Alcoholism Diabetes Melitus Pancreatitis Anal Fissure Diverticulitis Pulmonary Arterial Hypertension Arythmia Emphysema Pulmonary Embolism Barrets Esophagus Fibrocystic Breast Pulmonary Hypertension Breast Mass GI Disease Significant Trauma or Injury Burn Injury Groin Hernia TIA Cancer Hemangioma Ventral or Incisional Hernia Cholelithiasis Hiatal Hernia Wound Dehiscence Cirrhosis Liver Disease Wound Infection Colon Cancer Liver Mass Other (please specify below) Colon Polyps Obesity Cardiovascular Disease Obstructive Sleep Apnea 2. If you have or have had any other medical conditions not listed here, please specify. rthwest Hospital & Medical Center University of Washington Physicians PAGE 2 OF 6
3 General Medical History 1. Have you had any of the following (please check all that apply): Medical Problems CHF Heart Attack Musculoskeletal Allergies COPD Heart Murmur Osteoporosis Anemia Depression Hepatitis PPD Anesthesia Problems Diabetes Type 1 HIV Seizures Anxiety Diabetes Type 2 Hypertension Stroke Arthritis GERD Insomnia Substance Abuse Asthma Glaucoma Kidney Disease Thyroid Disorder Bleeding/Clotting Disorder GYN Lipid/Cholesterol Tuberculosis Blood Transfusion Headaches Lung Disease Other (Please list below) Cardiovascular Disease 2. If you have or have had any other medical conditions not listed here, please specify. Past Surgical History 1. Have you had any of the following (please check all that apply): Surgeries Cholecystectomy Hernia Repair Splenectomy Adrenalectomy Colonoscopy Joint Replacement Thyroidectomy Anorectal Surgery Colon Resection Laparotomy Tubal Ligation Anti-Reflux Surgery Cosmetic Surgery Liver Resection Valve Replacement Appendectomy Esophageal Myotomy Pancreas Resection Vasectomy Bariatric Surgery Hemorrhoidectomy Prostate Other (Please list below) CABG Hysterectomy Small Bowel Resection 2. Have you had any previous surgeries for this problem? o o oo Surgeries for This Problem and if they helped Surgeon Year 3. If you have had any other surgeries, please specify. rthwest Hospital & Medical Center University of Washington Physicians PAGE 3 OF 6
4 Family History: Check all that apply to you and your family members PERSONAL HISTORY FAMILY HISTORY Illnesses: You Family Which family member(s) Alcoholism Allergic/Atopic Disease Asthma Bleeding Disorder Cancer Coronary Artery Disease Diabetes Heart Failure Heart Murmur Hyperlipidemia Hypertension Liver Disease Migraine Headaches Myocardial Infraction Obesity Osteoporosis Renal Disease Rheumatoid Arthritis Seizure Stroke Thyroid Disease Other (please specify) If you have other significant family history, please specify: rthwest Hospital & Medical Center University of Washington Physicians PAGE 4 OF 6
5 REVIEW OF SYSTEMS General Ear / se / Mouth / Throat Eye Neurology Heart Lung Skin Please review and check no or yes box Any current problems with your health? Comments Additional information Current Height: Weight: lbs Recent Weight gain / loss Fatigue / Trouble sleeping Fever / Chills / Night sweats Anesthesia Problems (self) Anesthesia Problems (family member) Hearing Loss / Hearing Aid Ear Problems se Problems Mouth or Throat Problems se bleeds / Sinus Problems Dental Problems / Dentures Loose or Missing Tooth / Teeth Wear glasses / contacts Eye problems Yellowing of white part of the eyes Problems with vision Headaches / Dizziness Seizures Fainting / Unconsciousness Numbness / Tingling / Weakness Chest Pain Heart Murmur High Blood Pressure Recent Heart Attack / MI Artificial Heart Valve(s) Able to walk two flights of stairs Shortness of breath (day or night) Asthma Sleep Apnea / Snoring Difficulty sleeping Lung problems Recent cold or cough Masses / Bumps / Lumps Rashes Lesions/ Cuts /Scrapes Wounds / Blisters rthwest Hospital & Medical Center University of Washington Physicians PAGE 5 OF 6
6 REVIEW OF SYSTEMS Continued Please review and check no or yes box Any current problems with your health? Comments Additional information Stomach / Gastrointestinal / Colon / Rectum Muscles / Bones Urinary Tract Male / Female Issues Reproduction Blood / Lymph Immunological Endocrine Mental Health Stomach / Abdominal pain Hiatal hernia Heartburn / Indigestion Nausea / Vomiting Diarrhea Constipation Blood in Stool Jaundice / Yellowing of skin Hepatitis A, B, or C Joint pain (where) Back pain /Disc disease Sprain / Strain Stiffness / Arthritis Artificial joint(s) Other physical disability Urinary Problems Pain with urination Kidney Problems / Kidney Stones Male or Female Specific Problems Females - Could you be pregnant? Bleeding problems Anemia Swollen or enlarged glands Hay fever Allergies HIV / Aids Heat / Cold intolerance Hyperthyroid / Hypothyroid Increased thirst / Diabetes Anxiety / Depression Psychiatric Care Other Concerns Patient Signature: Date: Provider Signature: Date & Time: rthwest Hospital & Medical Center University of Washington Physicians PAGE 6 OF 6
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
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All Other Medications, Dose Times per day Reason for taking the medication. Phone #
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PATIENT MEDICAL HISTORY PATIENT INFORMATION
PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s)
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Salt Lake Orthopaedic Clinic Initial Visit Form
Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Pre-Admission Testing Questionnaire
Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered