Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

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Transcription:

Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements. No medications Medication Name Dosage Frequency Medication Name Dosage Frequency *** If more room is needed please use back of form or attach a list of all current medications** Medication Allergies: (please list reaction next to allergy)

Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: Please list all past Surgeries No previous surgeries _ 2450 NE Mary Rose Place Suite 210 Bend, regon 97701 541.383.2200 fax 541.383.5170

Family History Does anyone in your family have a history of cancer? If yes what type of cancer and in which family member? Age/Age at Death Living Disease History/Cause of Death Father Yes / No Mother Yes / No Sibling (s) Yes/ No Children Yes/ No 3

Social History Fill in the bubbles completely (no check marks) Single Married Widowed Separated Divorced Retired Unemployed Employed Self-employed Student ccupation: If Retired, from what occupation: Smoking /Chewing Tobacco Currently Quit Year quit: Never How long have you (or did you) smoke(d)? How many cigarettes do you (or did you) smoke per day? How often do you smoke? (Circle one) Everyday Some days How soon after you wake up do you smoke your first cigarette? (Circle ne) 5 minutes 6-30 minutes 31-60 minutes after 60 minutes Alcohol Rarely Socially Daily Quit Never How much alcohol do you drink Recreational drugs No Yes Quit If yes/quit, what type? Current IV Drug use No Yes History of IV Drug use No Yes 4

Past Medical History: Check all of the following that you have experienced or have ever been diagnosed with in the past: Please fill in Circle completely (no check marks) Heart: YES: N: YES: N: Chest pain/chest tightness Heart disease Heart attack Heart murmur High Cholesterol Type I diabetes Ins. dependent Type 2 diabetes Lupus Kidney/Bladder: Kidney stones High blood pressure Kidney disease Ear-Nose-Throat-Lungs: Asthma Renal failure, acute Renal failure, chronic CPD Emphysema Tuberculosis General: HIV ther Medical History not listed: Anemia Anxiety disorder Cancer Type: Depression Hypothyroidism Musculoskeletal: YES: N: Arthritis Gout steoporosis 5

Abdomen: YES N Barrett's esophagitis Blood in stool Cirrhosis Colon polyps Constipation Diarrhea Diverticulosis Neurological YES N Migraines Parkinson's disease MS Alzheimer s Stroke Seizures Stomach ulcer Fatty liver Gall bladder disease GI bleed, lower GI bleed, upper Hepatitis B Hepatitis C Hemorrhoids Hernia type Irritable bowel syndrome (IBS) Ulcerative colitis Reflux 6

Review of systems Fill in all of the following that apply to this visit today only Please fill in the bubbles completely (no check marks) Constitutional YES: YES: Fatigue Shortness of breath Fever ENT/Respiratory Loss of appetite Change in voice Unexplained weight change Gain Loss Cough Gastroenterology Musculoskeletal Abdominal pain Joint pain Blood in stool Joint swelling Change in bowel habits Hematology Constipation Unexplained Bruising Diarrhea Easy bleeding Heartburn Dermatology Nausea Hives Vomiting Skin cancer Cardiology Rash Chest pain Neurology Dizziness Headache Palpitations 7

Memory loss YES YES Genitourinary female Sleep Apnea Difficulty urinating Psychology Heavy periods Anxiety Painful periods Depression Number of Pregnancies: Eating disorder Number of deliveries: Mental or physical abuse Sexual abuse Genitourinary male Abnormal Tension/stress Difficulty urinating Hard testicle Incontinence or dribbling Increased urinary frequency 8

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