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Medical Questionnaire

Date:
Name: Gender: Male Female Age

Birth-date: Birth Place: Mother’s Birth Name:

Social Security Number: Driver’s License #:

Marital Status:    Single Married Spouse’s Name :

Married how long? Divorced Separated

Widowed


Language Spoken: Interpreter Required? Yes NO

Home Address:

City: State: Zip-code:

Phone: Fax:
Employer: Occupation:

Address: Phone:

City: State: Zip-code: Fax:
Emergency Contact:
(Not living in the same household)
Relationship:

Address:

City: State: Zip-code:

Phone: Fax:

Local Telephone Number:  (Relative, Friend or Hotel)
Referring Physician:

Specialty:

Address:

City: State: Zip-code:

Phone: Fax:
Other Physician:

Specialty:

Address:

City: State: Zip-code:

Phone: Fax:
Other Physician:

Specialty:

Address:

City: State: Zip-code:

Phone: Fax:

Periodic reports may be sent to your physician(s).To whom you would like them sent?  [Circle number(s)]  1.   2.   3.

Patient Name: Date of Birth: Date:
Height: Weight: SS# Spouse’s Name:
Allergies Yes No Do Not Know List Allergies Explain Reaction
Drugs
Food
Environmental

Medical History:

Bleeding Dizziness/ Fainting Infectious Disease Shortness of Breath
Blood Disease Edema Kidney Disease Skin Condition
Bone Disorder Gastrointestinal Mental Illness Stroke
Cancer Heart Disease Pain Thyroid Disorder
Chipped/Loose Teeth Hypertension Pulmonary Disease Personal History of Anesthesia problems
Dentures Implanted Device

(Shunt, Pump, pacemaker)

Seizures Family History of Anesthesia problems
Diabetes

**For Women:    Date of Last Menstrual Period (LMP):


Please list and describe any previous Hospitalization and/ or Surgeries:
Have you or family members had a previous history of anesthesia problems? (Explain)
Do you: Smoke: Yes No Amount:
Consume Alcohol Yes No Amount:

Medications

Name of Medication

Dose

Frequency

Last Dose

Comments

1.

2.

3.

4.

5.

6.

7.

8.

 

Present Illness
Please describe in your own words the date of onset of your illness, symptoms & treatment:

PATIENT NAME:

PATIENT NAME:

Please indicate if you have had or currently are experiencing any of the following. If you are not sure, please mark Do Not Know and we will be happy to assist you during your scheduled visit.

GENERAL

Condition

YES

NO

Do Not Know

1.

Swollen or enlarged (lymph) glands

2.

Diabetes

3.

Other tumors or cancer

4.

Mumps

5.

Rheumatic fever

6.

Scarlet fever

7.

Nervous disorders

8.

Gallbladder disease

9.

Venereal disease

10.

Hepatitis

11.

Cirrhosis

12.

Epilepsy


HEAD, EYES, EARS, NOSE THROAT - (HEENT)

Condition

YES

NO

Do Not Know

1.

Headaches

2.

Dizziness or fainting spells

3.

Eye injuries

4.

Double vision

5.

Blurring vision

6.

Eye pain

7.

Cataracts

8.

Glaucoma

9.

Earaches

10.

Ringing or buzzing in ear

11 .

Decrease / loss of hearing

12.

Sensation of spinning

13.

Sinus trouble

14.

Nose bleeding

15.

Sore tongue

16.

Bleeding gums

17.

Unusual trouble with teeth

18.

Skin disease

19.

Skin tumors /  moles removed or burned

20.

Chronic or frequent infections, colds


BREAST

Condition

YES

NO

Do Not Know

1.

Lumps in breast

2.

Pain in breast

3.

Nipple discharge


ENDOCRINE

Condition

YES

NO

Do Not Know

1.

Thyroid trouble or goiter

2.

Thyroid medication or tests

3.

Frequent Laryngitis

4.

Hoarseness or change in voice


HEART

Condition

YES

NO

Do Not Know

1.

Heart Disease

2.

Bleeding tendency or easy bleeding

3.

High Blood pressure

4.

Pain or pressure in chest

5.

Undue shortness in breath (day or night)

6.

Ankle Swelling

7.

Pain in legs while walking

8.

Fast or irregular heart beating (palpitations)

9.

Heart murmurs


PULMONARY

Condition

YES

NO

Do Not Know

1.

Chronic cough, coughed up blood

2.

Do you have the date of your last chest x-ray?

3.

Soaking sweats

4.

Exposure to TB

5.

Asthma


GASTRO INTESTINAL

Condition

YES

NO

Do Not Know

1.

Stomach, liveDizziness or fainting spellsr or intestinal trouble

2.
Recent gain or loss of weight. (lbs.)
Gain Loss
3.

Decreased appetite

4.

Difficulty swallowing

5.

Nausea or vomiting

6.

Frequent bowel movements

7.

Constipation

8.

Recent change in bowel movements

9.

Black bowel movements

10.

Blood in stools

11.

Jaundice


GENITOURINARY URINARY

Condition

YES

NO

Do Not Know

1.

Kidney trouble

2.

Frequent or painful urination

3.

Kidney stones

4.

Blood in urine

5.

Sugar or albumin in urine

6.

Slow starting of urine stream

7.

Passing urine at night


MUSCULOSKELETAL

Condition

YES

NO

Do Not Know

1.

Arthritis or rheumatism

2.

Back or bone pain

3.

Clumsiness/awkwardness of hands/feet

4.

Numbness or tingling of hands or feet

5.

Muscle pain or weakness


NEUROLOGIC

Condition

YES

NO

Do Not Know

1.

Forgetfulness

2.

Reactions to serum, drug or medicine

3.

Unusual fatigue

4.

Excessive worry

5.

Excessive depression

6

Nervous disorders

7

Sexual impotence

8.

Seizures

9.

Strokes

10.

Trans Ischemic Attack (TIA)

1.
Alcohol intake: Yes No
Indicate next to each the amount of drinks and Frequency – i.e. Daily, Weekly or Monthly.

1. Beer

2. Wine

3. Whiskey

4. Other

2.
Smoking: Cigarettes packs

PATIENT NAME:


Women Only

GYNECOLOGICAL

Condition

YES

NO

Do Not Know

1.

Vaginal bleeding following intercourse

2.

Painful menstruation

3.

Irregular or excessive menstruation

4.

Vaginal discharge

5.

Been treated for female disorder

6

Have you used an intrauterine device

7

Have you gone through menopause

Please list any past breast problems:


Are you taking hormones:

Have you ever taken birth control pills or hormones?
Type: how long?
When stopped?
Age of onset of menstruation:
Interval between periods:
Date of last period:
Number of pregnancies:
Number of births:
Number of abortions:
Your age at birth of your first child:
Family history of breast problems:
Date of your Last Menstrual Cycle (LMC):

PATIENT NAME:

Past Surgeries (Operations):
Please list in chronological order

DATE TYPE OF OPERATION REASON FOR SURGERY HOSPITAL DOCTOR

Other Hospitalizations:
Please list in chronological order

DATE TYPE OF OPERATION REASON FOR SURGERY HOSPITAL DOCTOR

Radiation Therapy Treatment:
Please list in chronological order
We need to know when treatment started and when it was completed.

STARTED? STOPPED? Area of Body Treated Hospital Doctor
Month Year Month Year

PATIENT NAME:

List any medications you are now taking, date that you started and the date you discontinued: (including over the counter / non-prescription drugs {i.e. Aspirins, Tylenol, Vitamins, Diet Pills, etc.}.


Pain Pills:
Tranquilizers:
Sleeping Pills:

Other:


Please list any medications to which you have had allergic reaction:

PATIENT NAME:

Family History:

RELATION AGE STATE OF HEALTH IF DECEASED – CAUSE OF DEATH AGE AT DEATH
Father  
Mother  
Spouse  
Brothers          
Sisters          
Children          

Have any of your blood relatives, husband, wife or children had any of the following?

YES NO (CHECK EACH ITEM) RELATION(S)
Tuberculosis
Diabetes
Cancer
Leukemia
Anemia
Bleeding Tendency
Heart Disease
High Blood Pressure
Kidney Disease
Asthma, Hay Fever, Other Allergy
Chronic Arthritis (Rheumatism)
Nervous Or Mental Disorder
Goiter
Emphysema
Any Other Illness
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