Patient Health History

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Transcription:

Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms related to your visit: c Pain c Instability c Infection 2. Other symptoms: 3. Location of symptoms: c Right Hip c Left Hip c Right Knee c Left Knee c Right Shoulder c Left Shoulder c Back Other: 4. Severity of symptoms: c Mild c Moderate c Severe c Constant c Intermittent c With Activity 5. Duration of symptoms: Days: Weeks: Months: Years: Please list all prior surgeries OR Type of surgery including Side/Area c No previous surgeries Estimated Year A. B. C. D. E. F. G.

6. Prior Hospitalizations other than surgery OR c No previous hospitalizations Reason for Hospitalization: Estimated Year A. B. C. D. 7. Medical Illnesses for which you are currently being treated for (i.e. high blood pressure, diabetes, heart disease, etc.) Please list on the next page (9) the name of the medication that you take for this condition. c NONE Condition: Estimated year at onset A. B. C. D. E. F. G. H. 8. Medication Allergies or Sensitivities (example: Penicillin causes rash) OR c NONE (NO KNOWN ALLERGIES) Name of Medication Reaction A. B. C. D.

9. Metal Allergies or Sensitivities (example: rash or blistering with any type of jewelry or metal-framed eyeglasses) c No known metal allergies c Metal allergies c Aluminum c Nickel c Other c Other c Other Additional Notes 10. List All Current Medications you are now taking or have taken in the last two weeks; including over the counter medications, herbal medications, inhalers, breathing machines, and/or oxygen, eye drops and topicals/ patches. Medication name Strength or dosage Time of day taken (AM, PM, bedtime) Number of pills taken each time Example: Lipitor 20 mg Bedtime One Reason for use High cholesterol

Medication name Strength or dosage Time of day taken (AM, PM, bedtime) Number of pills taken each time Reason for use

11. Have you ever received a blood transfusion in the past? If yes, did you have an adverse reaction to the blood transfusion? 12. Do you have any religious beliefs against receiving blood? 13. Have you ever had difficulty with anesthesia? If yes, please explain 14. Do you have any bleeding tendencies? (Example: bloody urine, bloody stools) If yes, please explain 15. Have any of your primary/direct family members (mother, father, brother, sister) had any of the following: NOT yourself --your family member c Unknown Blood clots in the legs or lungs Surgical complications Difficulty with anesthesia Heart disease (heart attack, angina, or chest pain) prior to age 60 Diabetes Bleeding tendencies or disorders If you answered yes to any of the questions about your family history in number 15, please explain: 16. Do you currently smoke or chew tobacco products? If yes, year you started? Number of packs per day at most were you smoking? Have you ever been a smoker in the past? How many years did you smoke? If you quit smoking, what year did you quit? Never used tobacco products c 17. Do you currently drink alcohol? Never c Number of drinks per day Number of drinks per week Number of years of alcohol use Have you had any medical complications from alcohol Have you had any withdrawal symptoms when not drinking? 18. Do you have any history of substance abuse or drug addiction?

Review of Systems: Do you have a personal history of the following? 19. General Recent unexplained weight loss Recent unexplained weight gain Recent unexplained fevers or chills Any recent infections? Do you exercise? If yes, how long and how often? HEENT Glasses Cataracts Glaucoma Hearing loss or wear hearing aids Dentures or partials Upper c Lower c Both c Active dental infection or tooth pain Cardiac High blood pressure Heart attack Congestive heart failure Heart valve replacement Open-heart surgery for bypass Did your heart doctor balloon open any of your heart arteries? Did your heart doctor stent any of your heart arteries? Do you have chest pain with exertion? Do you have swelling in your legs? Have you ever been told that you have a heart murmur? Do you have palpitations or rhythm disturbances? Heart Tests Have you ever had a cardiac stress test? Heart catheterization/ angiogram Echocardiogram (an ultrasound of your heart) If you answered yes, please state what year and the name of where you had the test performed: Name of Cardiologist (if applies) Date of last visit

Pulmonary Asthma, COPD, emphysema, or chronic bronchitis? Do you experience shortness of breath with exertion? Need to sleep propped up on 2 or more pillows due to breathing? Do you wake up at night with shortness of breath? Have you ever required treatment with oxygen at home? Do you have sleep apnea? If yes, do you use C-PAP c or Bi-PAP c Have you ever tested positive for tuberculosis (TB)? Do you have seasonal allergies or hay fever? GI Frequent diarrhea Frequent constipation Diverticulitis Irritable bowel syndrome Crohn s disease Ever had part of your colon removed or an intestinal surgery? Peptic ulcer disease/duodenal ulcer Intestinal bleeding Difficulty with swallowing Heartburn or gastro-esophageal reflux disease Abdominal pain History of severe post-operative constipation/ileus Liver disease or cirrhosis Date of last Colonoscopy/Endoscopy Genitourinary Current burning or pain with urination? Have you had a bladder infection/urinary infection in past 6 months or more than 3 in the past year? Prostate enlargement (if you re a man) Have you ever donated a kidney or had one removed? Kidney stones Have you ever been told that your kidneys weren t working as well as they should or that you have Chronic Kidney Disease? Receiving dialysis? If so who is your kidney doctor? Where do you go for dialysis? What days do you receive dialysis? Have you had trouble urinating after surgery or trouble in the past with urinary catheter insertion?

Musculoskeletal Have you ever been told that you have Rheumatoid Arthritis? Have you ever been told that you have Osteoporosis? Neurologic Stroke or TIA (mini stroke) Paralysis or temporary loss of strength, sensation, or vision Were you ever told that you are legally blind? Frequent fainting spells or dizziness Seizures Frequent headaches or migraine headaches Chronic neck or back pain Chronic pain syndrome Emotion/Mood Confusion or disorientation after surgery Anxiety for which you are being treated or are taking medicines Depression for which you are being treated or are taking medicines Any other emotional problems Endocrine High cholesterol Thyroid problems (underactive or overactive thyroid) Diabetes (this includes being borderline) Have you ever been in DKA (diabetic ketoacidosis)? If Diabetic HgBA1c (date/level) Typical AM fasting blood sugar Have you used steroids either as a pill or injection in the last month? Vascular Blood clots in your legs/lungs (DVT, phlebitis, pulmonary embolism) If yes, what was your treatment and for how long? Aneurysm, if yes where Have you ever had surgery on any of your arteries? (This includes stent, balloon procedure, or bypass of the leg arteries) If yes, where was your surgery? Do you have pain in the legs, buttocks or calves with walking? Other Anemia or Low Blood Count Elevated White Blood Cell Count

Unusual or frequent infections Poor wound healing Current open wound Pressure ulcers/ bed sores Currently pregnant or have been in the last 3 months If you re a woman, have you gone through menopause? Do you take hormone replacement therapy or birth control? Have you ever had cancer of any kind? If you answered yes, where was/is the cancer? What was/is your treatment? Who was/is your cancer doctor? Have you ever had an organ transplant? If yes, when and what organ? Who is the doctor that follows your progress? If you have answered yes to any of the above-mentioned questions please explain: Form completed by: Date: If other than the patient, please identify the relationship: Reviewed by: Date:

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