RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY 317-880-6825 Today s Date: Date of Birth Phone # Alternate # Age Height Current weight Significant other Name: Reason for Visit Referring MD Email address: DO YOU HAVE A HISTORY OF: (please specify past and current problems) Heart/Circulation Problems Yes No Yes No High Blood Pressure Heart attack: month/year Low Blood Pressure Irregular heart beat Stroke Swollen ankles/legs Anemia/sickle cell anemia Angina/chest pain Bleeding problems Pacemaker Blood Clots/DVT Cardiologist (heart MD) Lung or Breathing Problems Yes No Yes No Asthma Tuberculosis (positive PPD) last attack Bronchitis Chronic cough Pneumonia Shortness of breath Chronic lung disease If yes: at rest, walking, climbing stairs Sleep Apnea Sinusitis Emphysema Abnormal chest xray Pulmonary Embolism Pulmonologist Digestive or Liver Problems Yes No Yes No Heart burn/ acid reflux Abdominal pain Difficulty swallowing Stomach ulcers Vomiting Nausea Diarrhea Jaundice (yellow skin) Constipation Hepatitis Change in bowel habits Gastroenterologist Endocrine Problems Yes No Yes No Diabetes: Thryoid: Diet controlled Hypothyroidism Medicine controlled Hyperthyroidism Insulin Endocrinologist
Urinary, Kidney, Bladder Yes No Reproductive (females) Yes No Urinary Tract Infection Menstrual problems Painful urination Last menstrual period date Frequent urination Menopause Blood in urine Number of pregnancies Kidney stones Number of live births Renal Failure Breastfeed children? Dialysis Other female problems: Urologist _ OB/GYN Head/ Neurologic Problems Yes No Yes No Seizures/Epilepsy Peripheral Neuropathy Frequent headaches Myasthenia Gravis Blackouts ALS Paralysis Multiple Sclerosis Numbness or tingling Weakness in arms or legs Neurologist _ Skeletal Problems Yes No OTHER Yes No Arthritis Mental illness Physical disability Depression Back problems Anxiety Joint replacement HIV or AIDS Other Cancer (specify type, Right, Left, Both) Eye/Ear Yes No Yes No Dry eyes Hearing problems/hearing aid Obstructed vision Vision changes Glaucoma/cataracts Contacts/glasses (Men only need to complete following if being seen for breast complaints) BREAST Yes No Current Bra Size Yes No Nipple numbness Nipple inversion Breast pain Nipple discharge Breast lumps History of breast cancer? Right/Left/Both Please circle if applies: Lumpectomy Mastectomy Chemotherapy Radiation Previous breast reconstruction Breast pain Shoulder pain Back/neck pain Rashes under/between breast Arm numbness Mammogram Date Results **Please have faxed to 317-656-4061
MEDICATIONS: (include prescriptions and over the counter medicines, including aspirin, vitamins, etc.) Medicine Dosage (amount taken daily) Do you take any of the following homeopathic products or dietary supplements? Y N Y N Y N Y N Echinacea Ginseng Melatonin Vitamin E Ephedra Fish Oil St. John s Wort Valerian Ginkgo Biloba Green Tea ALLERGIES: (please include what happens to you when you take the medication) Medicine Side effect/allergic reaction SURGICAL HISTORY:(include type and year of surgery) Surgery Type Year Surgery Type Year ENT Heart Tonsils Vascular Hernia Back Gallbladder Neck Stomach Joints Appendix Hysterectomy Colon Breast Cosmetic Implant Gastric Bypass Other surgeries (include year of surgery)
Have you ever received any blood/ blood products If yes, any reactions (what type) Any problems with anesthesia? Describe: Have you been exposed to a cough/cold/uti/sinus infection/illness in the last 2 weeks? Describe: Y N PREVENTATIVE SCREENING: Date of most PAP Smear Bone Density Test Endoscopy Colonoscopy recent EKG Chest Xray Blood work/labs Physical Exam Date of most recent Primary Care MD: Phone# Pharmacy Name: Phone# SOCIAL HISTORY: Occupation How long? Please circle: Right handed or Left handed Are you presently: Single Married Separated Divorced Widowed Tobacco Use Cigarettes Pipe/cigars/chewing tobacco Nicotine gum/patches/lozenges/ecigarettes None Recreational drugs List: How much How many years Date Quit Alcohol use Daily Weekly Monthly Amount Do you have a history or alcohol or substance abuse? **Please write your initials that you understand that your surgery may be canceled if you are currently smoking and that a urine nicotine test may be done at any time. Initial here FAMILY HISTORY: (please indicate relationship- M=mother, F=father, S=sibling, G=grandparent) Diabetes Coronary Artery Disease Stroke Sickle Cell Anemia Heart Attack Mother Alive? Father Alive? Y N Y N Seizures Bleeding Problems Melanoma Mental illness Cancer If yes, please specify type
May we discuss your condition with: (please indicate who) Comments: In order to provide you with the best care we may need to get information from your other doctors. May we contact your health care providers to discuss your care? Yes No Are you currently under the care of a psychiatrist or psychologist? Yes No If yes, for what condition? Have you discussed having surgery with your psychiatrist/psychologist? Yes No Please sign and date that all the information provided is accurate and to the best of your knowledge. Signature Date