orthwest Georgia Surgical Specialists, PC Medical History Form ame Date of visit Last First MI Day ear Date of Birth Age Gender Marital Status Height Weight Day ear Referring Doctor Reason for Visit PAST MEDICAL HISTOR Pulmonary/Lung Disease Emphysema COPD Asthma Bronchitis Pneumonia Sleep Apnea Tuberculosis eurologic/psychiatric Depression Bipolar d/o Schizophrenia Cardiovascular/Heart Disease Angina Heart Attack Heart Failure Irregular rate Murmur Mitral Valve Prolapse Aortic Valve Disease Pulm. Hypertension Stroke TIA Rheumatic Fever Peripheral Vasc Dis. Carotid A Disease Anorexia Bulemia Binge Eating Migraines
PAST MEDICAL HISTOR Gastrointestinal Disease Musculoskeletal/Rheumatologic Peptic Ulcer Dis Fibromyalgia Diverticulosis Collagen Vasc Dis GERD Scleroderma Hiatal Hernia Gout Crohns Disease Autoimmune Dis Ulcerative colitis Irritable Bowel ET/Opthalmologic Jaundice Hepatitis Glaucoma Gallbladder dis Vision Problems Colon Cancer Hearing Loss Colon Polyps Dentures Esophageal varices Caps/Crowns Cirrhosis Loose Teeth Hemorrhoids Glasses/Contacts Pancreatic disease Chronic Sinusitis Renal/Kidney Disease Hematologic/Blood Disease Kidney Stones DVT Dialysis Pulm Embolus UTI HIV Prostate swelling Anemia Prostate Cancer Leukemia Lymphoma Endocrine Diabetes Thyroid disease Adrenal disease Pituitary disease
Review of Systems Please indicate if you have had any of the following symptoms in the past 6 months: General Cardiovascular Fevers Chest pain Chills Swelling in feet ight Sweats Pain in calf muscle Weight loss when walking Weight gain Irregular heartbeat Change in appetite Difficulty lying flat to Difficulty Sleeping sleep Skin Gastrointestinal Growth on skin Indigestion/heartburn Change in color or size Difficulty swallowing of moles ausea Bleeding from moles Vomiting Constipation EET Diarrhea Frequent ose Bleeds Blood in stool Change in vision Change in bowel habits Lymphatics Genitourinary Swollen glands/lymph Burning or pain with nodes urination Endocrine Blood in urine Difficulty urinating Heat or cold intolerance Bubble or air in urine Frequent Urination Difficulty urinating Excessive thirst Respiratory Musculoskeletal Joint pain or stiffness Persistant or bothersome cough Central ervous Shortness of breath System Coughing up blood Frequent headaches Seizures
Surgical History Abdominal Appendectomy Cholecystectomy Gastrectomy Small Bowel Resection Splenectomy Surgery for bowel obstruction Hernia Pelvic Surgery Hysterectomy Removal of Ovary Ectopic Pregancy C section Amputation specify specify Head/eck Surgery Bariatric Surgery Gastric bypass Gastric Band Tonsillectomy Thyroid surgery Ear surgery Sleeve Gastrectomy Duodenal Switch VBG Breast Surgery Mastectomy Vascular Surgery Aneurysm Carotid Other Breast Biopsy Lumpectomy Breast Implant Tram reconstruction Orthopedic Surgery Hip replacement Rotator cuff repair Knee replacement Knee surgery, other Have you ever had problems with Other Surgical Procedures: general anesthesia? Do you have any family history of problems with general anesthesia? Do you have latex allergies? Do you have betadine allergies?
Social History Occupation Marital Status Married Single Divorced Widowed Tobacco Use Cigarettes Smokeless Tobacco Packs per day Alcohol Use Beer Wine Hard Liquor Bottles per day Glasses per day Drinks per day Family History Father Mother Sibling Sibling Sibling Colon CA Breast CA Ovarian CA Prostate CA Hypertension Heart Attack High Cholesterol Diabetes Bleeding Disorder Please make note of any other family history issues:
Health Maintenance Please note the approximate date and result of your most recent: Complete Physical Exam: ever ear Cardiac Stress Test ear ever Colonoscopy ear ever Women Mammogram ear ever Pap Smear ear ever Men PSA ear ever