Patient Health History Form

Which surgery center is your procedure taking place at?
Name:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
Surgery/Procedure Reason:
Surgeon:
Surgery Date:
Family Doctor:
Phone:
Do you have an Advance Directive?

List Past Surgeries or ProceduresYearComplications if any

ALLERGIES: SEE PATIENT MEDICATION RECONCILIATION FORM
Do you currently or have you ever had:If Yes, Explain
Heart 
High Blood Pressure
High cholesterol
Chest Pain/Angina
Heart Attack. What year?
Cardiac Stents. What year?
Open Heart Surgery / Bypass
Artificial Heart Valves
Pacemaker / Difibrillator
Irregular Heartbeat / Rate
Rheumatic Fever
Heart Murmur / Mitral Valve Prolapse
Congestive Heart Failure
Raynaud's/Peripheral Vascular disease
Lungs 
Recent Cold / Bronchitis / Pneumonia
Chronic Cough
Asthma
Emphysema/COPD
Able to lay flat?
Shortness of Breath
Tuberculosis
Home Oxygen
Any Other Lung Problems
Activity Level 
Do you get short of breath or have chest pain climbing a flight of stairs?
Do you get short of breath or have chest pain while performing light housework, i.e. cleaning, vacuuming, dusting?
Neuromuscular 
Stroke. When?
Seizures/Epilepsy
Migraines
Anxiety/Depression
Muscular Dystrophy
Fibromyalgia
Other Neurological problems
Anesthesia Complications 
Malignant Hyperthermia
Difficult Intubation
Difficulty Recovering
Nausea / Vomiting
Motion Sickness
Other Medical Conditions 
Cancer (Where / What Type)
Arthritis
Joint replacements
Metal in/on body
Anemia/Clotting Disorders
Ever had MRSA / VRE / Shingles?
Endocrine 
Diabetes
Thyroid disease
Steroid use
Hypoglycemia
Gastrointestinal 
Heartburn/Reflux
Ulcers/Gastritis
History of vomiting blood
Swallowing problems
Crohn's / Colitis / IBS
Chronic Constipation / Diarrhea
Blood in Stool
Kidney, Liver 
Hepatitis / Jaundice / Cirrhosis
Kidney Disease / Dialysis
Airway 
Difficulty Opening Mouth Fully / T.M.J.
Sleep Apnea / CPAP
Snoring
Eye, Ear, Nose, Throat 
Chronic Eye Problems / Glaucoma
Contacts / Glasses
Hearing Loss / Hearing Aids
Dentures / Partials
Bridgework / Caps / Crowns
Loose Teeth
Smoking, Alcohol, Other
Recreational Drug Use:
Smoking: Packs per day/# of years:
Drinks per week:

Females: Date of last period:
Anything that we can do to make your surgery more comfortable? (ex. Extra pillows, etc.)

Any other medical conditions? Please List:


Name of Person driving you home:
(Please note: It is our policy that your driver must remain on these premises during your short stay with us. We will not begin your procedure until your driver is present. Thank you for your kind cooperation.)


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