Elbow Patient History Form Page 4
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8Past Medical History
·Please check any of the following conditions you have or have had in the past.
·If you are unsure, please ask a staff member to assist you in filling out this form.
You
m ay
c heck
m ore
t han
o ne
c ondition.
I have no medical problems
Hypertension (High Blood Pressure)
Hypercholesterolemia (Elevated Cholesterol)
Alcoholism
Hypothyroidism
Anemia
Kidney Disease
Anxiety
Liver Disorder (Cirrhosis, Hepatitis)
Asthma
Lung Disease
Arthritis - rheumatoid (verified with blood test)
Osteomyelitis
Arthritis - osteo, degenerative
Parkinson's
Bowel disease
Ulcer Disease
Cancer (specify)_______________________________
Osteoprosis
Cardiac Arrhythmia (Abnormal heart rate)
Other (specify all other)_____________________________
Congestive Heart Failure
___________________________________________
Coronary Artery Disease (Angina)
___________________________________________
Cerebrovascular Disease (Stroke)
Diabetes
Depression
Have you ever had a blood transfuion?
Yes
No
Have you ever had a blood clot?
Yes
No
Past Surgical History
·Please check any of the following surgical procedures you have or have had in the past.
I have never had surgery.
Year of Most
Year of Previous
Recent Surgery
Surgery
Appendectomy
_____________
_____________
CABG (Coronary Artery Bypass Grafting)
_____________
_____________
Cholecystectomy (Removal of Gallbladder)
_____________
_____________
Hysterectomy
_____________
_____________
Mastectomy
_____________
_____________
Herniorrhaphy (Hernia Repair)
_____________
_____________
Tonsillectomy
_____________
_____________
Splenectomy (Removal of Spleen)
_____________
_____________
Discectomy - Cervical Spine
_____________
_____________
Discectomy - Lumbar Spine
_____________
_____________
Fusion - Cervical Spine
_____________
_____________
Fusion - Lumbar Spine
_____________
_____________
Fracture Repair – Ankle
_____________
_____________
Right
Left
Both
Fracture Repair – Knee
_____________
_____________
Right
Left
Both
Fracture Repair – Shoulder
_____________
_____________
Right
Left
Both
Hip replacement
_____________
_____________
Right
Left
Both
Arthroscopy – Knee
_____________
_____________
Right
Left
Both
Cartilage surgery/meniscus
_____________
_____________
Right
Left
Both
Ligament reconstruction – ACL
_____________
_____________
Right
Left
Both
Ligament reconstruction – other
_____________
_____________
Right
Left
Both
Knee replacement
_____________
_____________
Right
Left
Both
Arthroscopy – Shoulder
_____________
_____________
Right
Left
Both
Rotator cuff surgery
_____________
_____________
Right
Left
Both
Shoulder replacement
_____________
_____________
Right
Left
Both
Shoulder stabilization
_____________
_____________
Right
Left
Both
Other (List all others) _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
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