Northwest Surgical Specialists, LLP
Adult Medical History Form
Full Name: __________________________________
Date of Birth: ____________________________________
Reason for seeking medical care today, (include symptoms and how long): __________________________________________
________________________________________________________________________________________________________
Your Primary Care Provider: ________________________________________________________________________________
Other Providers involved with your care: ______________________________________________________________________
Email (Not work-related): _________________________________________________________________________________
*Demographics: (Please circle a response below)
Race:
American Indian or Alaskan Native Asian Black or African American White Unknown Declined
Ethnicity:
Not Hispanic or Latino origin Hispanic or Latino Declined
Preferred Language: Chinese English French Russian Spanish Somali Vietnamese Sign Language Declined
Need interpreter: Yes
No
Your preferred method of Contact: Home phone Cell phone Letter Secure Email
*Health Maintenance:
Last Mammogram: (month/year): __________
Last Colonoscopy: (month/year): __________
Are you older than 65: Yes No If yes, have you had a pneumovax vaccine: Yes
No
*Review of Symptoms: (Circle all that apply)
GENERAL: Fever Chills Night Sweats
EYES: Double Vision Loss of Vision
EARS/NOSE/THROAT: Swallowing difficulty Masses or lumps in your neck
ENDOCRINE: Unusually thirsty Unusually Hungry Chronically fatigued/tired Unusual weight loss Unusual weight gain
NEUROLOGICAL: Episodes of numbness and tingling of arms and legs Loss of balance Seizures Memory problems
CARDIOVASCULAR: Chest pain Sense of rapid or irregular heartbeat Foot or leg swelling Racing heart rate
Calf/leg pain when walking Wound/Ulcers on foot or leg
RESPIRATORY: Difficulty breathing during activities Unable to lie flat or sleep
Loud snoring or episodes of stopping breathing while asleep Chronic cough (day or night)
GASTROINTESTINAL: Difficulty swallowing Heartburn Recent change in bowel habits Abdominal pain Nausea/Vomiting
Yellowish skin color Loss of bowel control Bleeding from your rectum
GENITOURINARY: Urinary tract infection Painful urination Loss of urine control
MUSCULOSKELETAL: Leg weakness Muscle pains Trouble walking
PSYCHIATRIC: Anxiety Depression Phobias/Unusual fears Memory problems
(Circle if this applies): None of the above
Please list any problems not covered elsewhere: ______________________________________________________________
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*Risk Factors (Circle all that apply)
Tobacco Use:
Current everyday smoker Current some days/occasional smoker Former smoker
Never smoked
If you smoke, please circle the amount: less than ½ pack/day 1 pack/day more than 1 pack/day
Alcohol Use: Yes
Caffeine Use: Yes
No #drinks/week______
No #cups/week_______
HIV/High Risk Behaviors: (Circle all that apply)
Do you currently have more than1 sexual partner Sex with a prostitute
Illicit Drug Use: Yes
No
Reviewed by:
(Provider Signature)
Unprotected sex
Shared needle use
None
Northwest Surgical Specialists, LLP
Adult Medical History Form
*Past Medical History (Circle all that apply):
HX of Cancer:
Bladder Cancer
Brain Cancer
Breast Cancer
Cervical Cancer
Colon Cancer
Esophageal Cancer
Head/Neck Cancer
Kidney Cancer
Leukemia
Liver Cancer
Lung Cancer
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Rectal Cancer
Skin Cancer
Stomach Cancer
Uterine Cancer
Abdominal Aortic
Aneurysm
Alcoholism
Anemia
Anesthetic Complication
Angina
Arrhythmia
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Autoimmune Problems
Bleeding Disorder
Blindness
Blood Clotting Disorder
Breast Disease
Breast Lumps
Chest Pain
Cirrhosis
Congestive Heart Failure
Coronary Artery
Disease
Crohn's Disease
Deafness
Dementia
Depression
Diabetes Type I
Diabetes Type II
Dialysis
Diverticulosis
Diverticulitis
DVT (Blood Clots)
Fibromyalgia
GERD
Gout
Headaches
Heart Disease
Hypertension
Hyperlipidemia
HIV/AIDS
Kidney Disease
Kidney Stones
Liver Disease
Lung/Respiratory
Disease
Lupus
Mental Illness
Multiple Sclerosis
Myocardial Infarction
Osteoporosis
Pancreatitis
Peptic Ulcer
Peripheral Vascular
Disease
Pulmonary Embolism
Rectocele
Renal Artery Stenosis
STD
Stroke
Suicide Attempt
Thyroid Disease
TIA
Ulcerative Colitis
Circle Below if you
have no significant
past medical history:
No Significant Past
Medical History
Other:
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
*Past Surgical History (Circle all that apply):
Breast Surgery:
Breast Biopsy: Right Left
Lumpectomy: Right Left
Simple Mastectomy:
Right Left
Mod. Rad. Mastectomy:
Right Left
Sentinel Lymph Node
Removal:
Right Left
Axillary Lymph Node
Removal:
Right Left
Endocrine Surgery:
Thyroidectomy-total
Thyroidectomy-partial
Parathyroidectomy-total
Parathyroidectomy-partial
Adrenalectomy
Splenectomy
Lung Surgery:
Lung Removal: Right Left
Lung Lobe Removal:
Right Left
Heart Surgery:
Coronary Artery Bypass
Graft
Coronary Stent
Pacemaker
Abdominal Surgery:
Appendectomy
Gallbladder removal
Colon Surgery
Small Bowel Surgery
W Ileal Pouch
J Ileal Pouch
Colostomy
Ileostomy
Esophageal Hernia Surgery
GERD Surgery
Esophagus Removal
Pancreatic Surgery
Rectopexy
Incontinence Surgery
Vascular Surgery:
Carotid Artery Surgery
Aortic Aneurysm Surgery
LUE AV Fistula
RUE AV Fistula
LUE AV Graft
RUE AV Graft
LLE AV Graft
RLE AV Graft
Vein Surgery
Laser Vein Surgery
L Leg Bypass
R Leg Bypass
Aorto-BiFem Bypass
Amputation
Kidney Surgery:
Nephrectomy
Renal Transplant Surgery
PD Catheter Surgery
Hernia Surgery:
Inguinal hernia repair:
(circle)
Right
Left
Open or Laparoscopic
Umbilical Hernia repair:
Ventral Hernia repair:
Rectal Surgery:
Hemorrhoid Banded
Hemorrhoidectomy
Fissurectomy
Sphincterotomy
Pilonidal Abscess I&D
Pilonidal Surgery
Orthopedic Surgery:
(Explain)
Joint Replacement:
_________
_______________________
Spine Surgery:
_______________________
Reviewed by:
(Provider Signature)
Bariatric Surgery:
Gastric Bypass
Lap Band Surgery
URO/GYNE:
Hysterectomy
Urology Surgery
Gynecology Surgery
Urinary Incontinence
Surgery
Pelvic Prolapse repair
Prostate Surgery
____________________
Circle below if you have not
had any previous surgeries:
No Previous Surgery
_____________________
OTHER:
_____________________
_____________________
_____________________
_____________________
_____________________
Northwest Surgical Specialists, LLP
Adult Medical History Form
Full Name:
Date:
*Prescription Medication List: (If no prescriptions, circle none): NONE
Example:
Prescribed Medication:
Prilosec
Dosage:
Example: 20 mg
Times per day taken/ Frequency
Example: 3 x day
*Over-The-Counter (OTC) Medication (If no OTC medication, please circle none): NONE
OTC Medication:
Example:
Vit D 3
Dosage
Example: 5000mg
Frequency
Example: Daily
*Allergy History: (If no allergies, circle none): NONE
Medication Allergy:
Example:
Sulfa
Type of Reaction
Example: Hives, Rash, Anaphylaxis
Reviewed by:
(Provider Signature)
Severity of Reaction
(please circle one)
Severe Moderate Mild
Severe Moderate Mild
Severe Moderate Mild
Severe Moderate Mild
Severe Moderate Mild
Severe Moderate Mild
Northwest Surgical Specialists, LLP
Adult Medical History Form
*Your Family Medical History (Circle all that currently apply):
Coronary Heart Disease- Females(diagnosed before age of
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65)
Coronary Heart Disease- Males (diagnosed before age of 55)
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Anemia
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Anesthetic Problems
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Autoimmune
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Abnormal Bleeding
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Blood Clotting Disorder
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Brain Cancer
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Breast Cancer
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Cervical Cancer
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Colon / Rectal Cancer
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Dialysis
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Diabetes
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Heart Disease
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High Blood Pressure
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High Cholesterol
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Kidney Disease
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Kidney Cancer
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Lung Disease
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Lung Cancer
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Melanoma
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Ovarian Cancer
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Pancreatic Cancer
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Polyposis, Familial adenomatous
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Prostate Cancer
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Seizures / Convulsions
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Stroke /CVA
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Thyroid Disease
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Family Medical History: Unknown
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Family medical History: Not significant
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Family History of Breast Cancer
Family History of Ovarian Cancer
+Breast cancer, <50 yrs. old
+ Ovarian Cancer & Ashkenazi
Family History of Colon Cancer
+Colon Cancer, <60yrs old
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
+Breast Cancer, bilateral
+ Ovarian Cancer, at any age
Circle: Mother, Father, Sibling, Grandparent
+FAP, Familial adeno. polyposis
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
+Breast Cancer, > 2 primary
+Breast & Ovarian Cancer
+ HPNCC, Non-hereditary polyposis
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
+Breast Cancer, male at any age
+ Turcot Syndrome
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
+Breast & Ovarian Cancer
Family History of Other Cancers
Circle: Mother, Father, Sibling, Grandparent
+Peutz-Jeghers
Circle: Mother, Father, Sibling, Grandparent
+Breast Cancer & Ashkenazi heritage
+ Melanoma & Pancreatic Cancer
Circle: Mother, Father, Sibling, Grandparent
Circle: Mother, Father, Sibling, Grandparent
+ BRACA Mutation
Circle: Mother, Father, Sibling, Grandparent
Reviewed by:
(Provider Signature)