Medical History Form
Name ________________________________________________________________________________________
Reason for Consultation _______________________________________________________________________
Referring Physician ______________________________Primary Care Physician________________________
Past Medical History
Check all that apply and list details/diagnoses
□ Heart Attack/Heart Disease □ Congestive Heart Failure
□ COPD □ Thyroid Problems □ Asthma □ Stroke
□ Diabetes
□ High Blood Pressure
□ Heart Failure □ Hepatitis B □ Hepatitis C
□ Emphysema
□ AIDS/HIV
□ Coagulation or Bleeding Disorder (you may take Plavix or Coumadin for)
□ Sleep Apnea □ Cancer _________________________________________________________________
Other Medical Problems and Details:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SURGICAL HISTORY: Including Defibrillators, Pacemakers, or Stents
Operation
Date
Operation
Date
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills,
herbs, aspirin or blood thinners.
Medication
Dose
Times per
Day
Medication
Dose
Times Per
Day
CENTRAL TEXAS SURGICAL ASSOCIATES
ALLERGIES or REACTIONS:
□ None
Medication
□ Latex
Reaction or Side Effect
FAMILY HISTORY:
Please check all that apply.
Medical Condition
Anesthesia Problem
Asthma
Bleeding Problem
Breast Cancer
Colon Cancer
Melanoma
Thyroid Cancer
Parathyroid Cancer
Prostate Cancer
Diabetes
Heart Attack
High Blood Pressure
Kidney Disease
Leukemia
Lupus
Lymphoma
Stroke
Vascular Disease
Living
Deceased
Mom
Dad
Sister
Brother
Daughter
Son
Other
SOCIAL HISTORY
Tobacco Use
Cigarettes:
□ Never □ Current Smoker: Packs/day______ # of Years ________
□ Quit: Date _____________ How many years did you smoke? _____________
Other Tobacco:
□ Pipe
□ Cigar
□ Snuff
□ Chew
□ No
□ Yes: # of Drinks/Week _________________
Alcohol Use
CENTRAL TEXAS SURGICAL ASSOCIATES
Is your current Illness/problem work related? ____yes ____no
Please Indicate Below If You Are Currently Experiencing Any of These Symptoms:
General, Constitutional
Does your job require heavy lifting
Recent Weight Gain
Recent Weight Loss
Fever
Fatigue
Musculoskeletal
no
no
no
no
no
yes
yes
yes
yes
yes
Joint Pain
Back Pain
Muscle Pain or Cramps
Difficulty in Walking
no
no
no
no
yes
yes
yes
yes
Skin and Breasts
Change in Skin Color
Varicose Veins
Breast Pain/Tenderness
Breast Lump
Breast Discharge
Rash or itching
Healing Problems
no
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
yes
Eyes and Vision
Wear Glasses or Contact Lenses
no
yes
Ears, Nose, Throat
Swollen Lymph Nodes
Trouble Swallowing
no
no
yes
yes
no
yes
Neurological
no
no
yes
yes
Frequent Headaches
Light Headed or Dizzy
no
no
yes
yes
no
no
yes
yes
Seizures
Tremors
no
no
yes
yes
no
no
no
yes
yes
yes
Psychiatric
Memory Loss or Confusion
Nervousness/Anxiety
Depression
no
no
no
yes
yes
yes
Endocrine
Excessive Thirst
Excessive Urination
no
no
yes
yes
no
no
no
no
no
yes
yes
yes
yes
yes
Heart and Cardiovascular
Shortness of Breath with activity or
exertion
Chest Pains
Sudden Heartbeat Changes/Irregular
Heartbeat/Palpitations
Swelling of Feet, Ankles, Hands
Murmurs
Respiratory
Persistent/Frequent Coughing
Shortness of Breath
Asthma or Wheezing
Gastrointestinal
Loss of Appetite
Change in Bowel Movements
Nausea or Vomiting
Frequent Diarrhea
Painful Bowel Movements or Constipation
Blood in Stool
Abdominal/Stomach Pain
Difficulty Swallowing
Heartburn
Hemorrhoids
Rectal Bleeding
no
no
no
no
yes
yes
yes
yes
no
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
yes
Genitourinary
Frequent Urination
Difficulty with Urination
Blood in Urine
Change in Force or Strain with Urination
Recurrent UTI
CENTRAL TEXAS SURGICAL ASSOCIATES
CURRENT SYMPTOMS CONTINUED
Hematological/Lymphatic
Slow to Heal After Cuts
Easily Bruise or Bleed
Anemia
no
no
no
yes
yes
yes
Breast Patient History
How many children have you had? ___________________
Your age when first child was born? ____________________
Did you breastfeed? _______________
Age at first menstrual cycle? __________________
Age at last menstrual cycle (If menopausal)? __________________
Onset of last menstrual cycle? ________________
Number of prior breast biopsies _________________
Have you had a hysterectomy? ____________ If so, what year? _____________________
Breast Implants? ___________________ If so, what year? ________________________
Do you take hormone replacement therapy? ____________ How many years? _____________
Do you do regular breast self exams? ______________
List family members with breast or ovarian cancer and their relationship to you:
________________________________________________________________________________________
________________________________________________________________________________________
Patient Signature: ____________________________________________
Date: __________________
Surgeon Signature: ___________________________________________
Date: __________________