PATIENT HISTORY
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Check NO or YES to each question - If Yes, Enter year when occurred (circle if more than one choice):
Heart/Circulation
No
If yes, what year?
Heart problems?
Congestive Heart Failure
Pacemaker/auto defibrillator?
Irregular heart beat?
Heart murmur?
Rheumatic Fever?
High Blood Pressure?
Do you become short of breath with exertion?
Fainting or blackout spells?
Lung/Breathing
No
If yes, what year?
Breathing problems? (asthma, emphysema, COPD, pneumonia)
Do you use oxygen at home? (note how many liters/min)
Does child use respiratory medications, inhalers?
Tuberculosis?
Has anyone told you that you stop breathing @ night?
Has anyone told you that you snore loudly?
Do you use CPAP or BiPAP?
Do you become short of breath with exertion?
Fainting or blackout spells?
Smoking
Never
Currently
Past
Packs per day
blanks
Number of years
blank
Neurologic
No
If yes, what year?
Stroke or paralysis? (Multiple Sclerosis, polio, Muscular Dystrophy)
Seizure disorder?
Sciatica, pinched nerves, curved spine?
Alzheimers, Parkinson's?
Developmentally delayed?
Panic / anxiety attacks?
Mental illness? (bipolar, schizophrenia)
Depression, suicidal thoughts, attempts?
Have you had previous surgeries? (If yes, list type and year)
Stomach/Digestion
No
If yes, what year?
Heartburn / hiatal hernia?
Hepatitis/jaundice, or serious liver disease?
Ulcer / stomach problems?
Blood in stool?
Current diarrhea?
Bladder/Kidney
No
If yes, what year?
Kidney Failure?
Bladder/kidney/prostate problem?
Endocrine
No
If yes, what year?
Diabetes?
Thyroid disorder?
Low blood sugar?
Musculoskeletal
No
If yes, what year?
Arthritis?
Cervical fusion, Back & Disc problems?
Fractures?
Blood
No
If yes, what year?
Anemic?
Problem with blood clotting?
Previous blood transfusion?
Would you agree to a blood transfusion if needed?
Allergies to:
Tape
Iodine
Latex
Foods
Pollen/Dust
Shellfish
Other
If yes to food allergies, list below:
Reactions:
Medication Allergy
Yes
No
Medication Allergy
Name
Reaction
Medication
Medication
Medication
Medication
Medication
Other
No
If yes, what year?
(Oct - Dec) Have you had a flu shot?
Had pneumonia vaccine?
Recent international travel?
Sensory impairment? (speech/vision/hearing)
Glaucoma?
Skin problems?
Cancer?
HIV positive or AIDS?
Your age
blanks
Height
inches
Weight
Anesthesia
No
If yes, what year?
Do you have motion sickness?
Nausea/vomiting related to anesthesia?
Personal or family history of high fever during anesthesia (Malignant hyperthermia)?
Have you used steroids within the last six months?
Females: Are you or could you be pregnant?
When was the last time you used recreational drugs?
How many beers/cocktails/wine do you drink per week?
Current Medications: Include prescription, patches, nebulizers, sprays, drips, non-prescription, herbs, vitamins, minerals, & supplements.
Name
Dose
Time you take them
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Back
Next
Patient History
(Page 2 of 2)
Patient Name
First Name
Last Name
Please list all past surgeries:
Surgery
Year
1.)
2.)
3.)
4.)
5.)
6.)
List any other medical problems:
List Here
1.)
2.)
3.)
4.)
5.)
Completed by:
Patient
Staff
Signature
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