name today's date: / / birth date: | | social security · trtrtrtr 8trtrtr tr[trf trtrfi...
TRANSCRIPT
PAST MEDICAL AND SOCIAL HISTORY
Name Today's Date: / /
Birth Date: | | Social Security #:
PLEASE CHECK THE BOXES WHERE APPROPRIATE TO YOUR MEDICAL CONDITIONSE NONE FeportedE AnemiaE AnginaE A*hritis , osteoE Arthritis, FlheumatoidE Asthmatt btpotar utsoroerll Bleeorng uisor0erlt utooo translustonE Blood Disorder , OtherI cancerE Cardiac Arrhythm jarl Cognative lmpairmentsJ DepressionE Diabetes, lnsulin DependentE Diabetes, Non Insulin DependentE Ear Disease, OtherE Ear lnfectionsE Ear TubesE Eating DisorderE Emphysema/COPD
fl Endocrine Disorder, OtherI Eye DiseaseX FibromyalgiaIl Gastroesophageal Flef lux Diseasefl claucomaE GoiterE HrvE Head TraumaE Hearing AidsE Hearing LossE Heart AttackE Heart Disease, OtherE Heart Valve ProblemE HepatitisE High Blood PressureE High CholesterolE Hyperthyroidism (Over Active)fl Hypothyroidism (Under Active)I Kidney Disease, otherI Kidney Disease, On DialysisE Kidney Stone
E Liver DiseaseE Lung Disease, OtherE LupusE Meniere's Disease/Labyrinthitisfl Migraine Headachesfl N/litral Valve ProlapseI v]ultiple scterosisI Ny'usculoskeletal Disorder, other,1 Nasal; Fracturef, Neurological Disease, Othertr Noise ExposureE osteoporosisE Parathyroid Problem (High Calc'um)E Parkinson's DiseaseE Seizure DisorderE Sexually Transmitted DiseaseE Sleep ApneaE strokefl Substance AbuseD Thyroid DiseaseD Thyroid NoduleLJ I UmOrS. Uenrgn
fi Other Medical Conditions;
fl Cancer Location:Date Diagnosed: E Treatmenl I Radiation E Surgery I Chemotherapy
Additional Cancer Related Information:
CHILDHOOD MEDICAL HISTORYI NoNE Reported E chickenpoxEADHD E childhood Hearing LossE Apgar Score Less than 6 E Developmental DelaysE Asthma E DiabetesE Birth Nilarks E Ear InfectionE Birth Weight Less than 3.3 E Head InjuryE Pounds I MeaslesE Born Premature I N4eningitisE cerebral Palsy I N.4ononucleosis
E Other Childhood lvledicai History Iniormation :
E trilumpsE PneumoniaE Recurrent CroupE Required lntubation at BirthrJ Hneumaltc FeverE RubettaE Speech DelayE Strep Throat
PREVIOUS HISTORY OFf, NONE ReportedE cardiac ArrhythmiaE Cardiovascular Collapse
PROBLEMS WITH ANESTHESIAn Diificult lntubationE Hyperthermia, MalignantE Nausea
S Took a long time lo wake upI Vocal Cord InjuryU Vomiting
Tuln page over to complete form on othet side. +-
PAST MEDICAL AND SOCIAL HISTORY continuedMEDICATIONSAllergies to Medications? D yes D t'tolf "Yes". olease list & Describe Reaction
Currently Taking Medication: E Yes E No lf "Yes" , Please list:1 A
2 5
o
PREVIOUS SURGERIESE nOrue Reportedf AngioplastyU Carotid EndarterectomvE other
E Coronary Artery Bypass Graft (CABG)iJ Coronary Artery StentingE Gastric Bypass
E Cardiac Defibri l latorf Pacemakerf Tonsil lectomy
SOCIAL HISTORYSMOKING HISTORY
E nONf reoortedE Current Every Day Smokerf Current Some Day SmokerE Former Smokerf, Smoke 1 1l2ppdf Smoke 1 ppdf Smoke 112 ppdf Smoke 2 ppd
ALCOHOL HISTORYE None reportedf Current Alcohol Use OccasionallvI Current Alcohol Use Rarelvf Current Excessive Alcohol Useil Former Alcohol Abusefl Former Alcohol Use OccasionallyE Never Used Alcohol
DRUG HISTORYE Denies Drug UseU Current Drug UserI,J Current l l legal lV Drug User,-l Current l l legal Inhalation Drug Usefl Current Prescription Drug AddictionE Former l l legal lV Drug UserE Former l l legal Inhalation Drug UsetJ Former Prescription Drug Addiction
EXERCISE HISTORY: E Currently None E Currently Darly f, Currently Several Times a Week E Currently Sporadic
OCCUPATION:
FAMILYHISTORY M = Mother F = Father S = Sister B=Brother O=Other
Hearingloss D tr t iJ XHeaftDisease f tr E rJ IHypertension trEt l 3trHyperthyroidism(overActive) E n I tr trHypothyroidism(underActive) tr t X tr f,KidneyDisease tr tr I tr IKidneyStones f, tr tr f IMental lllness tr tr t I E
MF S B ONONE reported nAlcoholism tAnesthesiaComplication tRlcedinn lliqnrdcr fCancer fDiabetes f,Emphysema/Asthma/COPD IHeadache, Chronic t
REVIEW OF SYSTEMSlN THE PAST MONTH. HAVE YOU HAD ANY PROBLEMS RELATED TO THE FOLLOWING I
IfntretfE
fDtr t ]E3trnf t r t rDftr t r t rt r t r t r t r8tr t r t rt r [ t r ft r t r f I
Noncontributory DParathyroid Disease (high calclum) trProblems with Anesthesia DSeizure Disorder EThyroid Cancer trThyroid Disease trTuberculosis DUnknown f
MF S B OEtfTEtrt rEtt rEI]t r f , t rt r f , t rTTft ]EE
CONSTITUTIONALSYSTEMSf Chi l lsf Fatiguef Feverf, Daytime Sleepinessf Sweatsf Weight Gainf Weight Loss
EARSf Hearing LossI Ear Painf Ringing
NOSEf Bloody NoseI ObsiructionE Post Nasal DripI Sense of Smel l ,f, Decreasedf Sinus Pressuref Sneezing
CARDIACf Chest Painf Tachycardia
(Rapid Heartbeat)
f Shortness of Breath f, not FlashesI Snoring f Intolerance to ColoI Wheezing
GASTROINTESTINALfl Constipationf DiarrheaI Heartburnf Indigest ion
MUSCULARf Arthrit isf Muscle Aches
RESPIRATORYf Cough
ENDOCRINEf Fatigue
HEMATOLOGICf Bleeding, easyI Bruising, easy
LYMPHATICf Enlarged Lymph Nodesf Neck Mass
ALLERGY/IMMUNOLOGrcf Allergies, Seasonalf Sneezingf Tongue Swelling
NEUROLOGICALf Dizzinessf Headachef Tremor
THROATf Altered Tastefl Halitosis (Bad Breath)f Hemoptysis (Blood)f Swallowing Diff icultyf Throat, Soref Voice Change
EYESf Diptopia (Double Vision)f lrritationf itctring
SKINf Skin DrynessE MRSA
This form was completed by:Signature (Required) Printed Name