Patient Info

PATIENT HISTORY FORM

IMPORTANT: Please complete this form and bring it with you to your appointment.

Name:
Age:
Weight:
Height:
Date:
Present Illnesses:
Do you have any heart disease, heart trouble or abnormality? Y N
Do you have high blood pressure? Y N
Do you have a cold? Y N
Any recent or long term problems with your lungs? Y N
Have you had jaundice, hepatitis, or liver trouble? Y N
Do you have diabetes? Y N
Do you have thyroid trouble? Y N
Do you have kidney trouble? Y N
Have you had any back pain or injury? Y N
Do you have any other illnesses? Y N
Personal and Social:
Do you smoke? Y N
If you do smoke, how much do you smoke and for how long?
Do you drink alcohol ? Y N
If you do drink alcohol, how much do you consume?
Do you take any recreational drugs? Y N
Surgeries:
Any previous surgeries? Y N
If Yes, When? Results? Please describe:
What type of anesthesia was used?
Allergies:
Do you have any allergies to medicine? Y N
If yes, Please describe
Any unusual reactions to anesthesia by you or a family member? Please describe:
Allergies:
Have you had a recent chest X-ray? Y N
Have you had a recent EKG? Y N
Have you had a recent blood test? Y N
Medications:
Are you taking any prescription drugs currently? Y N
If yes, list drug, dosage, and how often you take them.
Date of last medical check-up?
(women only) Date of your last OB/GYN exam?