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Name______________________________           Chart #________ Date___________________________

 

 

Primary Care Physician ________________          Address ___________________   Send Records: Yes/No

 

Age____ Sex____ Marital Status________                Occupation____________________________________

 

Height________________________________     Weight_______________________________________

 

Responsible Adult Available to Assist During Recovery Period:   Yes/ No    Relationship______________

 

 

HABITS

Smoke: Yes/No     Amount:____________          Coffee/Tea/Cola:    Yes /No      Amount:____________

 

Alcohol: Yes/No      Amount: ___________            Daily Exercise:          Yes/No       Amount:____________

 

 

MEDICATIONS

Do you take any medications? (prescribed or over the counter)  Yes/No

 

 

Prescription Drugs                                                        Non Prescription Drugs

__________________________________               _____________________________________________

__________________________________               _____________________________________________

__________________________________               _____________________________________________

__________________________________               _____________________________________________

__________________________________               _____________________________________________

__________________________________                  _____________________________________________

__________________________________               _____________________________________________

 

Yes/No    Regular Aspirin Use                                   Dosage & Frequency: ___________________________

Yes/No     NSAID (Advil, Motrin, Ibuprofen)            Dosage & Frequency: ___________________________

Yes/No     Cortisone Injections Past Year                Date(s) & Injection location: ______________________

 

 

Drug Allergies:       Yes/No        List Drug(s) & type of reaction: _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

 

Latex Allergy:      Yes/No                                      Tape Allergy:    Yes/No

 

 

 

                                                                                                                                   (Continued on Back)

PERSONAL PAST HISTORY: Circle Yes or No if you ever had the following problems:

Yes/No   Abnormal Bleeding           Yes/No   Asthma                            Yes/No   Hypertension

Yes/No   Abnormal Clotting              Yes/No   Diabetes                         Yes/No   Sleep Apnea

Yes/No   Acid Reflux                           Yes/No   Fainting Spell                 Yes/No   Snoring

Yes/No   Anemia                                  Yes/No   Heart Attack                  Yes/No   Weight Change past 12 mo.

Yes/No   Angina                                   Yes/No   Hepatitis                        Yes/No   Other _________________

 

Please describe any answered Yes:   _______________________________________________________________________________

_______________________________________________________________________________

Have you ever received a transfusion?   Yes/No   If yes, what year? ______________________________

 

Have you been tested for HIV? Yes/No         If yes, what year _______   Test results:   Positive   Negative

 

Do you wear Contact lenses: Yes/No             Eye glasses: Yes/No

 

Hearing Aid:   Yes/No                                         Dentures:       Yes/No

 

List Previous Surgeries, year and type of procedure: (Use back of page if needed) _____________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

 

Women Patients Only: Number of pregnancies____   Number of children________________________

Last Menstrual period____ Did you breast feed?   Yes/No       Last Mammogram ___________________

 

 

 

FAMILY HISTORY: Have any blood relatives ever had the following problems:

Yes/No     Abnormal Bleeding                    Yes/No     Coronary Surgery                     Yes/No    Kidney Disease

Yes/No     Abnormal Clotting                     Yes/No     Diabetes                                       Yes/No     Tuberculosis

Yes/No     Anesthetic Problems               Yes/No     Heart Attack                                  Yes/No     Other

 

Please describe if Yes: ___________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

 

 

 

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor responsible for

any errors or omissions that I may have made in the completion of this form.

 

 

 

_________________________   _________                       ______________________           ___________   Patient’s Signature                         Date                                            Physician’s Signature                       Date