VASCULAR SURGERY PATIENT HEALTH HISTORY

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VASCULAR SURGERY 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

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): Cerebrovascular Thrombosis, Medical Problems Disease Mesenteric Vein Portal Vein Thrombosis Acute DVT Chronic DVT Aortic Aneurysm Deep Vein Thrombosis Aortic Dissection Hemodialysis Pelvic Venous Insufficiency Peripheral Vascular Disease Thrombophlebitis Ulcers Access Renal Artery Disease Varicosities/Phlebitis A-V Malformation Lymphedema Renovascular Disease Venous Insufficiency 2. If you have or have had any other medical conditions not listed here, please specify. Portal Hypertension Other, please specify rthwest Hospital & Medical Center University of Washington Physicians PAGE 2 OF 6

General Medical History 1. Have you had any of the following (please check all that apply): Medical Problems Cardiovascular Disease Headaches Lung Disease Allergies CHF Heart Attack Musculoskeletal Anemia COPD Heart Murmur Osteoporosis Anesthesia Problems Depression Hepatitis PPD Anxiety Diabetes Type 1 HIV Seizures Arthritis Diabetes Type 2 Hypertension Stroke Asthma GERD Insomnia Substance Abuse Bleeding/Clotting Disorder GI Disease Kidney Disease Thyroid Disorder Blood Transfusion Glaucoma Lipid/Cholesterol Tuberculosis Cancer GYN Other (Please list below) 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 CABG Dialysis Renal Artery Stent Amputation Carotid Endarterectomy Fistula/Graft Splenectomy Aneurysm Repair Carotid Stent Placement Hysterectomy Transplant Appendectomy Cholecystectomy Peripheral Stent Placement Vein Surgery Arterial Bypass Coronary Angioplasty Vein Transplant Other (Please list below) 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

FAMILY HISOTRY Check all that apply to you and your family members PERSONAL HISTORY FAMILY HISTORY Illnesses: You Family Which family member(s) Alcoholism Amputations Aneurysms Arthritis Asthma Bleeding Disorder Cancer Clotting Disorder COPD Depression Diabetes Deep Vein Thrombosis Drug Abuse Early Sudden Death Hearing Loss Heart Attack Heart Disease Hyperlipidemia Hypertension Kidney Disease Miscarriages Stroke Varicose Veins Vision Loss Other (please specify) If you have other significant family history, please specify: rthwest Hospital & Medical Center University of Washington Physicians PAGE 4 OF 6

REVIEW OF SYSTEMS Please review and check no or yes box Any current problems with your health? Comments Additional information General Current Height: Weight: lbs Ear / se / Mouth / Throat Eye Neurology Heart Lung Skin 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

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

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