PERSONAL DETAILS AND SOCIAL PROFILE
Date:
Last Name:
First Name:
Home Address:
Middle Name:
Social Security #
Mailing Address:
Telephone No (Home):
(Bus):
Mobile No:
E-Mail:
Date of Birth:
Age:
Sex:
Occupation:
Health insurance:
Policy:
Proposed Surgical Date:
CONTACT PERSON
This information is often vital to us if we need to contact you urgently.
A.
Next of Kin:
Name:
Relationship:
Address:
Telephone No (home):
(Business):
B. Additional Contact:
Name:
Relationship:
Address:
Telephone No (home):
(Business):
C. Additional Contact:
Name:
Relationship:
Address:
Telephone No (home):
(Business):
FAMILY STRUCTURE
Married
Single
Partnership
Children / Ages:
Support person/friend:
REFERRAL INFORMATION
Referring Doctor:
Date of Referral:
Address:
Telephone No:
Local Doctor:
Address:
Specialist Physician/Surgeon:
Other:
MEDICAL HISTORY
PLEASE NOTE THAT AT THE END OF THIS SECTION THERE IS A PART TO LIST ALL CURRENT DRUGS
AND TREATMENTS USED BY THE PATIENT.
Accurate weight
Height
Allergies:
Penicillin
No
If Yes, What type?
Erythromycin
Tape
Yes
Sulfas
Cardiovascular
Hypertension:
Yes
High Cholesterol:
Yes
Myocardial Infarction Yes
Do you know your BMI (Body Max Index)?
No
No
No
Stable Angina:
Yes
No
Type of Treatment:
Angioplasty
Date:
Coronary Stent
Date:
Thrombolytic Therapy
What type?
Iodine
Latex
Date of Diagnosis:
Date of Diagnosis:
Date of the episode:
How Many
Don’t know
Arteries related
Kg/m2
Other
Arrhythmias:
Yes
No
If Yes,
Atrial Fibrilation
Date:
Ventricular Arrhythmia
Date:
Type of Arrhythmia or Diagnosis?
Electro ablation:
Yes
Pacemaker:
Yes
Automated Defibrillator Yes
No
No
No
Date:
Date of placement:
Date
Mitral Valve Prolapsed:
Yes
Coronary artery bypass graft (CABG): Yes
Varicose Veins:
Yes
No
No
No
Date of diagnosis:
Date
Edema: Yes
Deep Venous Thrombosis:
Days of hospital stay
Yes
No
Date of diagnosis:
Complications
Yes
No
No
Heparin: Yes
No
Infrarenal Filter (Greenfield Filter): Yes
Date of Procedure:
Coumadin:
Yes
No
Date of treatment:
How many months of treatment:
No
Other Procedures:
Pulmonary
Smoke:
Yes
No
Years of active smoking
Date of last day of smoking:
Pulmonary Embolism
Yes
No
Date
Oral Anticoagulants
Yes
No
Coumadin
Still taking Coumadin?
Yes
No
Sleep Apnea:
Yes
No
Nasal Clap
Yes
No
Asthma:
Yes
No
Cigarettes/Day
mgs/day
Last date of test PT/INR
Date of diagnosis:
Date of diagnosis:
Pulmonary Function Test performed? Yes
Nasal allergies:
Yes
No
Tuberculosis:
Yes
No
No
Date of diagnosis:
Treatment:
Other Procedures
Neurologic
Strokes:
Yes
No
Transitory Ischemic Attack (TIA):
Epilepsy:
Yes
No
If Yes, Date of diagnosis:
Yes
No
Date of diagnosis:
Date of diagnosis:
Seizures:
Yes
No
If Yes, last event:
Depression:
Yes
No
If Yes, Date of diagnosis:
Anxiety:
Yes
No
If Yes, Date of diagnosis:
Multiple Sclerosis:
Yes
No
If Yes, Date of diagnosis:
Cerebral Tumors:
Yes
No
If Yes, Date of diagnosis:
Cranial Surgery
Yes
Complications
No
If Yes, Date of Surgery:
Cervical (Neck) Surgery:
Complications
Yes
No
If Yes, Date of Surgery:
Lumbar (Back) Surgery:
Complications
Yes
No
If Yes, Date of Surgery:
Other Procedures:
Endocrinology
Diabetes: Yes
No
If Yes, Date of diagnosis:
Medications: Metformin
Insulin:
Rapid
Glyburide
NPH
Type I
Avandia
Lantus
Others
How many units a day?
Kidney Failure
Yes
No
Hemodyalisis Before? Yes
No
Retinopathy:
Yes
No
Neuropathy:
No
Ketoacidosis:
Yes
No
If Yes, Date of admission:
Hypothyroidism:
Yes
No
If Yes, Date of surgery:
Current Medications: Synthroid
Pituitary Adenomas: Yes
Levotiroxine
No
Type II
Yes
Armour Thyroid
Other
If Yes, Date of diagnosis:
Other Procedures:
Oncology
Cancer:
Prostate
(Specify)
Yes
Breast
Chemotherapy:
Surgery:
Radiation Therapy:
Hormone Therapy
Other Procedures:
Yes
Yes
Yes
Yes
No
Lung
If Yes, Date of diagnosis:
Colon
Liver
Cervical/Uterine
No
No
No
No
Obstetric and Gynecological Disease
Pregnancies:
Vaginal
Toxemia (Pre-eclampsia):
Yes
Other
If Yes, Date of treatment:
If Yes, Date of surgery:
If Yes, Date of treatment:
If Yes, Date of medication:
C-Section
Abortion
Miscarriage
No
If Yes, Date of diagnosis:
Gestational Diabetes:
Hormone replacement therapy:
Oral contraceptives:
PCOS (Polycystic ovary syndrome):
Other Procedures:
Yes
Yes
Yes
Yes
No
No
No
No
If Yes, Date of diagnosis:
Gastrointestinal and Liver Disease
Gastrointestinal Reflux Disease (GERD):
Diagnosis?
Clinical
Endoscopy
Yes
No
If Yes, Date of diagnosis:
Ph. Monitoring
Other:
Pancreatitis: Yes
No
If Yes, Date of episode:
Complications?
Hepatitis:
No
If Yes, Date of episode:
Complications?
Yes
Type A
Type B
Type C
Have you ever been diagnose with liver cirrhosis or portal hypertension? Yes
Other Procedures:
Renal History
Kidney Stones:
Yes
No
If Yes, Last episode:
Kidney Failure:
Yes
No
If Yes, Date of episode:
Hemodyalisis:
Yes
No
If Yes, Date of dialysis:
Kidney Transplant: Yes
Comments:
Uric Acid (Gout):
Yes
No
If Yes, Date of procedure:
No
Other Procedure:
Hematologic Diseases
Hemophilia:
Yes
No
Protein C Deficiency:
Yes
No
Yes
No
Other Hematologic disorder:
Anemia:
Other Procedures:
If Yes, Current treatment:
No
List of medications
Please do not leave any current medications out
Medication
Dosage
Times per day