Past Medical History
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Name:__________________________________Date of Birth___________Today’s Date_____________ Past Medical History Select any of the following medical conditions that you currently have Adrenal Insufficiency HIV / AIDS Anemia/Thalassemia Hypercholesterolemia Anxiety Hyperthyroidism Arthritis Hypothyroidism Asthma Lung Cancer Atrial Fibrillation (Irregular Heartbeat) Lupus Auto-Immune Disease Lymphoma Bipolar Disorder Malignant Hypertension Blood Clotting Disorder Mental Health Hospitalization BPH Neuromuscular Disorder Breast Cancer Paralysis Colon Cancer Pneumothorax COPD Prostate Cancer Coronary Artery Disease Pulmonary Embolism Deep Venous Thrombosis Radiation Treatment Depression Renal Disorder Diabetes Rheumatoid Arthritis Easy Bruising Seizures End Stage Renal Disease Severe Reaction to Anesthesia GERD Stroke Head Trauma Trauma Hearing Loss Valvular Heart Disease Hepatitis Vision Loss Hypertension None Pregnancy: Vaginal Delivery Cesarean Other________________________________ Past Surgeries Have you had any surgeries on the following organs? Abdominal Wall: Hernia Repair, Left Femoral Joint Replacement: Hip (Right) Abdominal Wall: Hernia Repair, Right Femoral Joint Replacement: Hip (Left) Abdominal Wall: Hernia Repair, Left Inguinal Joint Replacement: Hip (Both) Abdominal Wall: Hernia Repair, Right Inguinal Kidney: Kidney Biopsy Abdominal Wall: Hernia Repair, Umbilical Kidney: Nephrectomy Adenoidectomy Kidney: Kidney Stone Removal Abdominal Wall: Hernia Repair, Ventral Kidney: Kidney Transplant Appendix (Appendectomy) Lung: Left Lower Lobectomy Bladder (Cystectomy) Lung: Left Pneumonectomy Brain: Brain Surgery for Cancer Lung: Left Upper Lobectomy Brain: Brain Surgery for Trauma Lung: Right Lower Lobectomy Breast: Mastectomy (Right Breast) Lung: Right Middle Lobectomy Breast: Mastectomy (Left Breast) Lung: Right Pneumonectomy Breast: Mastectomy (Both Breasts) Lung: Right Upper Lobectomy Breast: Lumpectomy (Right Breast) Ovaries (Oophorectomy): Endometriosis Breast: Lumpectomy (Left Breast) Ovaries (Oophorectomy): Ovarian Cyst Breast: Lumpectomy (Both Breasts) Ovaries (Oophorectomy): Ovarian Cancer Breast: Breast Biopsy Prostate (Prostatectomy: Prostate Cancer Cesarean Section Prostate (Prostatectomy): Prostate Biopsy Colon (Colectomy): Colon Cancer Resection Prostate (Prostatectomy): TURP Colon (Colectomy): Diverticulitis Skin: Skin Biopsy Colon (Colectomy): Inflammatory Bowel Disease Skin: Basal Cell Carcinoma Esophagus: Esophagectomy Skin: Squamous Cell Carcinoma Gallbladder (Cholecystectomy) Skin: Melanoma Heart: Coronary Artery Bypass Surgery Small Bowel Resection Heart: PTCA Spine Surgery Heart: Mechanical Valve Replacement Spleen (Splenectomy) Heart: Biological Valve Replacement Stomach: Gastrectomy Heart: Heart Transplant Testicles (Orchiectomy) Joint Replacement: Knee (Right) Tonsillectomy Joint Replacement: Knee (Left) Uterus (Hysterectomy): Fibroids Joint Replacement: Knee (Both) Uterus (Hysterectomy): Uterine Cancer Other ____________________ None ______________________ Pediatric History Gestational Age at Birth (in weeks) Weeks Birth Weight lbs oz Maternal illness during pregnancy ______________________________ Forceps delivery Yes No Skin Disease History Have you had any of the following skin conditions? Acne Flaking or Itchy Scalp Actinic Keratoses Hay Fever/Allergies Asthma Melanoma Basal Cell Skin Cancer Poison Ivy Blistering Sunburns Precancerous Moles Dry Skin Psoriasis Eczema Squamous cell skin cancer Other None Do you wear Sunscreen? Yes No If yes, what SPF? _____ Do you tan in a tanning salon? Yes No Family History List first degree relatives with significant past medical history: _____________________________________________ ________________________________________________________________________________________________ Family History Do you have a family history of Melanoma? Yes No If yes, which relative? Mother Aunt Father Nephew Sister Niece Brother Grandmother Daughter Grandfather Son Grandson Uncle Granddaughter Other _________ Plastic Surgery History Abdomen: Abdominal Wall Reconstruction Face: Lower Blepharoplasty Abdomen: Abdominoplasty Face: Mandible Fracture Body Contouring: Brachioplasty Face: Maxillary Fracture Body Contouring: Liposuction Face: Orbital Floor Fracture Body Contouring: Lower Body Lift Face: Repair of Craniosynostosis Body Contouring: Thigh Lift Face: Upper Blepharoplasty Body Contouring: Upper Body Lift Face: Zygoma Fracture Breast: Breast Augmentation Flap Reconstruction Breast: Breast Lift (Mastopexy) Hair Restoration Breast: Breast Reconstruction Hand: Extensor Tendon Repair(s), Left Upper Extremity Breast: Breast Reduction Hand: Extensor Tendon Repair(s), Right Upper Extremity Breast: Correction of Nipple Inversion Hand: Flexor Tendon Repair(s), Left Upper Extremity Breast: Implant Removal Hand: Flexor Tendon Repair(s), Right Upper Extremity Breast: Nipple Reconstruction Hand: Ganglion Cyst Removal Burn Wound Reconstruction Hand: Mallet Finger Repair, Left Upper Extremity Carpal Tunnel Release Hand: Mallet Finger Repair, Right Upper Extremity Chemical Peel Hand: Metacarpal Fracture Repair Cleft Lip Repair Cleft Palate Repair Hand: ORIF of Fracture, Left Upper Extremity Cubital Tunnel Release Hand: ORIF of Fracture, Right Upper Extremity Decubitus Ulcer Reconstruction Hand: Phalangeal Fracture Repair Dermabrasion Hand: Trigger Finger Release, Left Upper Extremity Ears: Ear Reconstruction Hand: Trigger Finger Release, Right Upper Extremity Ears: Earlobe repair Hand: Wrist Fracture Repair Ears: Otoplasty Laser Hair Removal Face: Blepharoplasty Laser resurfacing - CO2 Face: Brow lift Laser resurfacing - Erbium Face: Cheek Augmentation Nose: Rhinoplasty Face: Chin Augmentation Nose: Septoplasty Face: Facelift Orthopedic Hardware Coverage Face: Facial Fracture Repair Scar revision Face: Facial Reanimation Skin Graft Reconstruction Face: Frontal Sinus Fracture Sternal Wound Reconstruction Face: Frontoorbital Advancement Tendon Transfer Face: Lefort Osteotomy Vascular Graft Coverage Other Plastic Surgery History __________________________________________ Wound Reconstruction Breast Cancer Do you have a family history of breast cancer? Yes No If so, which relative Mother Aunt Father Nephew Sister Niece Brother Grandmother Daughter Grandfather Son Grandson Uncle Granddaughter Other ___________ Malignant Hyperthermia and Anesthesia Sensitivity Do you have a family history of malignant hyperthermia or severe reactions to anesthesia? Yes No If so, which relative Mother Aunt Father Nephew Sister Niece Brother Grandmother Daughter Grandfather Son Grandson Uncle Granddaughter Other ___________ Herbal Medications and Supplements Do you take any herbal medications or supplements? Yes No Which herbal medications or supplements do you take? Anabolic Steroids Hawthorn Androstenedione HCG Black Cohosh Horse Chestnut Cat's Claw Human growth hormone Chondroitin Kava Cranberry Licorice Root Echinacea Mistletoe Ephedra Peppermint Evening Primrose Phentermine Feverfew Red Clover Fish Oil Saw Palmetto Flaxseed Oil St. John’s Wort Garlic Valerian Gingko Biloba Vitamin A Ginseng Vitamin B Glucosamine Vitamin C Goldenseal Vitamin D Green tea Other__________________ Vitamin E Medications List all current medications: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Pharmacy: Name, Address & Phone________________________________________________________________________________ _____________________________________________________________________________ Allergies: List all allergies and reactions if known:___________________________________________________________________________ _____________________________________________________________________________ Occupation and Workplace:______________________________________________________ Social History Social History Details Not sexually active EtOH none Sexually active with one partner EtOH less than 1 drink per day Sexually active with more than one partner EtOH 1-2 drinks per day Same sex partner EtOH 3 or more drinks per day Drug use Patient feels safe at home IV Drug Use Patient feels unsafe at home Other __________________________ Right hand dominant Left hand dominant None Smoking Status (please choose one) Current everyday smoker Current someday smoker Former smoker Never smoker Smoker current status unknown Unknown if ever smoked Driving Status Drives in the Daytime Drives at Night How often do you exercise? Unspecified Several times a day Once a day A few times a week A few times a month Never Other ____________ What is your caffeine use? Unspecified Several times a day Once a day A few times a week A few times a month Never Other ____________ Preferred Language: _____________________ Preferred Contact Method: Unspecified Declined to receive reminders Patient Portal Phone: Home:______________________ Cell:____________________ Is it Ok to leave a detailed message: Yes or No Letter/Fax Race and Ethnicity: Race: Unspecified Declined to specify Prohibited by State law Prohibited White American Indian/Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander Other Abenaki Other Race Ethic Group: Unspecified Declined to specify Prohibited by State law Hispanic or Latino Not Hispanic or Latino Unknown Review of Systems: Are you currently experiencing any of the following: (Please check yes or no for the following): Abdominal Pain yes no Anxiety yes no Bleeding Problems yes no Bloody Stool yes no Bloody Urine yes no Changing Mole yes no Chest Pain yes no Cough yes no Depression yes no Fever or Chills yes no Headaches yes no Hay Fevers yes no Joint Aches yes no Muscle Weakness yes no Neck Stiffness yes no Night Sweats yes no Rash yes no Seizures yes no Shortness of Breath yes no Sore Throat yes no Thyroid Problems yes no Unintentional Weight loss yes no Wheezing yes no Other Symptoms:_______________________________________________ Cautions: (Circle all that apply) Have you ever had difficulty-stopping bleeding? yes no Do you require antibiotics prior to surgical procedure? yes no Have you had an artificial joint replacement? yes no If yes, when and what body locations?___________________________ Do you have an artificial heart valve? yes no Do you have a pacemaker? yes no Do you have a defibrillator? yes no Are you pregnant or currently trying to get pregnant? yes no Patient Name:_____________________________________Date___________________
