Medical History Form
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1Medical History
NAME:
DOB:
HEIGHT:
WEIGHT:
SURGEON:
SURGERY:
DATE OF SURGERY:
LIST ALL ALLERGIES TO MEDICATIONS
LIST ALL PREVIOUS SURGERIES OR PROCEDURES REQUIRING SEDATION
Metal Implants: Location _____________________
□ YES □ NO
Have you ever had anesthesia
□ YES □ NO Have you ever had problems with anesthesia, if Yes please list in Comments
□ YES □ NO
Have you or a relative ever been diagnosed with Malignant Hyperthermia (MH) ?
Whom:
WHAT is the most activity you can do before you get tired or short of breath: □ Walk across room □ Walk up 2 flights of stairs □ Run 1 mile
CHECK ALL THAT APPLY TO YOU NOW OR IN THE PAST
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
□ YES □ NO
High Blood Pressure
□ YES □ NO Cough/Cold last 2 weeks
□ YES □ NO Ulcer
□ YES □ NO
Palpitations/Irregular Heart Beat
□ YES □ NO Asthma/Wheezing
□ YES □ NO Hiatal Hernia
□ YES □ NO
Valve Prolapse
□ YES □ NO Emphysema
□ YES □ NO Frequent Heartburn
□ YES □ NO
Heart Murmur
□ YES □ NO Bronchitis
□ YES □ NO Acid Reflux
□ YES □ NO
Congestive Heart Failure
□ YES □ NO Sleep Apnea ______ CPAP use
□ YES □ NO Other GI Disease
□ YES □ NO
Angioplasty/ Stent - Year _____
□ YES □ NO TB ______
□ YES □ NO Hepatitis
□ YES □ NO
Pacemaker/Defibrillator
□ YES □ NO Allergies/Sinusitis (Hayfever)
□ YES □ NO Other Liver Disease
KIDNEY
□ YES □ NO
Brand/Model of Device ______
□ YES □ NO COPD
□ YES □ NO
Coronary Artery Bypass Grafts
□ YES □ NO Home 02
24 Hours
□ YES □ NO Kidney Failure
□ YES □ NO
Heart Attack - Year ______
# Liters of 02 __________
Night Only
□ YES □ NO Kidney Stones
□ YES □ NO
Angina/Chest Pain
ENDOCRINE
□ YES □ NO Frequent Urinary Infections
□ YES □ NO
Coronary Artery Disease
□ YES □ NO Diabetes
Type 1
Type 2
□ YES □ NO Other Kidney disease
□ YES □ NO
High Cholesterol
□ YES □ NO Other Endocrine Diseases
□ YES □ NO Dialysis
□ YES □ NO
Blood Clots
□ YES □ NO Steroid Medications in Past Year
BLOOD
□ YES □ NO
Rheumatic Fever
ASSISTIVE DEVICES
□ YES □ NO Bleeding Disorder
□ YES □ NO
Anemia
□ YES □ NO Dentures - Full Set
□ YES □ NO Sickle Cell
NEUROLOGICAL
□ YES □ NO Partial - Bridge
□ YES □ NO Hemophilia
□ YES □ NO
Seizures/Epilepsy
□ YES □ NO Glasses/Contact Lens
□ YES □ NO Other Blood Disease
□ YES □ NO
Stroke/ Paralysis
□ YES □ NO Hearing Aids
□ YES □ NO Blood Thinners
□ YES □ NO
Muscle Weakness/ MS
Cane
Crutches
Wheelchair
□ YES □ NO Blood Transfusion- Year ____
□ YES □ NO
Parkinsons
OTHER
SOCIAL
□ YES □ NO
Mental Disorder
□ YES □ NO Arthritis
□ YES □ NO Have you ever smoked Yrs ____
□ YES □ NO
Spinal Cord Abnormality
□ YES □ NO TMJ
Packs per Day ______
□ YES □ NO
Other Neuro Disease
□ YES □ NO Cancer: Type ________________
Year Quit ______
□ YES □ NO
Migraines
□ YES □ NO Glaucoma
□ YES □ NO Drink Alcohol
□ YES □ NO
Head Trauma
□ YES □ NO History of MRSA
Drinks per week ______
PEDIATRIC PATIENTS
□ YES □ NO Long Term Antibiotic Use
□ YES □ NO Do you use medical marijuana
□ YES □ NO Premature Birth
□ YES □ NO Chewing/Swallowing Difficulties
□ YES □ NO Have you ever used street drugs
□ YES □ NO Family history of muscle disease
Special Diet: ______________________________
□ YES □ NO HIV/AIDS
Custody: _________________________________ □ YES □ NO
Resides in Long Term Care Facility: List: ____________________________________
Primary Physician: _________________________
Comments: Please include any other medical history
Cardiologist: ______________________________
Date Last Menstrual Period ____________
CONTACT INFORMATION
Number you can be reached at: DAY _________________________ NIGHT________________________ □ YES □ NO Can we leave a msg on a machine
Someone must be available after your surgery for instructions, to take you home and stay with you or your surgery will be cancelled
Emergency Contact:____________________________________________________
Caregiver: __________________________________
□ Same as Emergency Contact
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