Medical History

Please fill out this secure form; your information will be treated securely and with confidentiality.

General Information

The following information is necessary to help your doctor make important decisions regarding your medical care. Please check any appropriate boxes below, and answer the questions thoroughly.


Review of Systems

Please indicate if you are currently experiencing any of these symptoms by checking the appropriate box below.

Constitutional




Eyes/Vision*


Ears, Nose, Throat *


Heart/Cardiovascular *


Respiratory *


Gastrointestinal *


Genitourinary *


Musculoskeletal *


Skin and Breasts *


Neurologic *


Endocrine *


Hematologic/Lymphatic *


Psychiatric *


Allergies

Do you have any allergies? *

If you have any allergies, please click "yes" and notate them in the dropdown box that opens below.



Medications


Do you take any of the following medications, homeopathic products or dietary supplements? If you are taking any of the medications or other products listed below, you must discontinue use fourteen (14) days prior to surgery or as instructed by our office. Note well: Your surgery will be canceled if you do not discontinue these medications as directed.

Accutane - AlertMD

Advil

Alka-Seltzer tablets

Alka-Seltzer Plus Cold

Alleve

Anacin (capsules and tablets)

Anacin maximum strength (capsules and tablets)

APC tablets

APC with Codeine, Tabloyd Brand

Arthritis Formula by the makers of Anacin tablets

Arthrotec

Ascodeen - 30

Ascriptin

Aspirin

Aspergum

Aspirin Suppositories

Anaprox

Bayer Aspirin 81mg

Bayer Children's Chewable Aspirin

Bayer Children's Cold Tablets

Bayer Time-Released

BC Powders

Bilberry

Buff-a-Comp Tablets

Buffadyne

Bufferin

Bufferin Feldene

Buttalbital

Bextra

Cama Inlay Tablets

Cataflam

Celebrex

Centrum Silver

Centrum Vitamins

Cetased, Improved

Cheracol Capsules

Chinese Herbals

Clinoril

Congespirin

Cope

Corcidin D Decongestant Tablets

Corcidin for Children

Corcidin Medilets (tabs for children)

Corcidin Tablets

Coumadin (Warfarin)

Darvon

Darvon with Aspirin

Darvon-N with Aspirin

Diet Pills

Disalid

Dolobid

Dristan Decongestant (tablets and capsules)

Duragesic

Ecotrin

Empirin

Empirin with Codeine

Emprazil Tablets

Emprazil-C Tablets

Ephedra

Equagesic

Excedrin

Fiorinal with Codeine

Four (4) Way Cold Tablets

Garlic

Gemnisyn

Ginger

Goody's Headache Powders

Ginko Biloba

Glucosamine

Ibuprofen

Indocin

Licorice Root

Lodine

Measurin

Melatonin

Meloxicam/Mobic

Metabolife

Midol

Momentum Muscular (backache formula

Monacet with Codeine

Mono-Gesic

Motrin

Nalfon

Naprelan

Naprosyn

Norgesic/Norgesic Forte

Norwich Aspirin

Orudis

Oruvail

Pabirin Buffered Tablets

Panalgesic Percodan

PC-SPEC

Percodan Demi Tablets

Pentoxifylline

Persistin

Plavix

Pletal

Quiet World Analgesic/Sleeping Aid

Robaxisal Tablets

Salsalate

SK-65 Compound

St. John's Wort

St. Joseph's Aspirin for Children

Sine-Aid

Sine-Off Sinus Medicine/Aspirin

Sofarin

Stendin

Sero-Darvon with Aspirin/Sulindac

Supac

Synalgos Capsules

Tolectin

Toradol

Trental

Trilasate

Triamcinilin

Verin

Viromed Tablets

Vitamin E

Voltarin

Warfarin

Yohimbe

Zoprin



Hospitalization



Medical History *

Do you have (or have you had): (Explain in the dropdown box that appears if you check a condition below.)

  Glaucoma

  Diabetes

  Hyperthyroidism

  Hypothyroidism

  Hypertension

  Heart Disease

  Vascular Disease

  Heart Attack

  Hepatitis

  Stomach Ulcers

  Gastroesophageal Reflux

  Irritable Bowel Syndrome

  Sleep Apnea

  Asthma

  Pneumonia

  Valley Fever

  Tuberculosis

  Emphysema

  Kidney Stones

  Urinary Tract Infection

  Renal Failure

  Bleeding Disorder

  Blood Clotting Problem

  Deep Vein Thrombosis

  Pulmonary Thromboembolism

  Anemia

  Fibrocystic Breast Disease

  Mental Illness

  Neurologic Disease

  Peripheral Neuropathy

  Myasthenia Gravis

  Asymptrophic Lateral Sclerosis

  Multiple Sclerosis

  Stroke

  Seizures

  Obesity

  Gout

  Arthritis

  HIV or AIDS

  Lupus

  Scleroderma

  Cancer

  Other (not mentioned above)



Surgeries/Accidents/Injuries

Previous Surgeries? *

(Please indicate the year of any surgery you have had)

Cosmetic Surgery *

Ear Surgery *

Tonsils Surgery *

Neck Surgery *

Nasal Surgery *

Sinus Surgery *

Eye Surgery *

Eyelid Surgery *

Breast Surgery *

Back Surgery *

Joint Surgery *

Thyroid Surgery *

Gall Bladder Surgery *

Appendectomy *

Hemorrhoid Surgery *

Colon Surgery *

Gastric Bypass Surgery *

Hernia Surgery *

Stomach Surgery *

Hysterectomy *

C-Section *

Heart Surgery *

Coronary Artery Bypass *

Carotid Bypass *

Peripheral Vascular Surgery *

Other Surgery? *

Have you ever had any problems with anesthesia? *



About You

Your Occupation? *

Marital Status? * Are you presently:


Smoking History? *


Alcohol Consumption: *


Recreational Drugs: *



Family History

Is there a family history of any of the following problems?*


Parents



End Bits

Yes
 


Thanks.