PATIENT HEALTH HISTORY
Have you had: (Check all that apply)
Have you had:
Yes
No
Heart Attack ☐
Chest Pain ☐
Murmur ☐
Hiatal Hernia
☐
☐
Congestive Heart Failure ☐
Seizures
☐
☐
Coronary Artery Disease ☐
Yes
No
Last episode:
Heart Surgery? If yes, when?
☐
☐
Stroke / TIA If yes, when:
☐
☐
Heart Valve Disease or Rheumatic Fever?
☐
☐
Parkinsons Disease
☐
☐
Do you use Nitroglycerin?
☐
☐
Neuro-muscular problem
☐
☐
If yes, how frequent?
☐
☐
☐ Paralysis ☐ Numbness ☐ Weakness
Irregular of Fast Heartbeat
☐
☐
Where
High Blood Pressure
☐
☐
☐ Hard of hearing ☐ Deaf
☐
☐
Pacemaker or Implanted Defibrillator
☐
☐
Hearing aids: ☐ Left ☐ Right
☐
☐
☐ Asthma ☐ Emphysema ☐ Bronchitis
☐
☐
☐ Anxiety ☐ Panic attacks
☐
☐
TB If yes, when:
☐ Claustrophobia
☐
☐
Do you use inhalers?
☐
☐
Do You:
Recent respiratory infection
☐
☐
Take blood thinners or Aspirin?
☐
☐
Chronic or current cough
☐
☐
Use Alcohol If yes, amount
☐
☐
Short of breath: ☐ At rest ☐ With activity
☐
☐
Smoke If yes, amount per day
☐
☐
Do you use oxygen at home?
☐
☐
If in past, when did you quit
☐
☐
☐ All the time ☐ Only at night
Cancer
☐
☐
Who is your primary doctor:
Diabetes
☐
☐
Bad reaction to anesthesia
☐
☐
Controlled by: ☐ Diet ☐ Oral agent ☐ Insulin
☐ Self ☐ Relative
Advance Directive: ☐ Yes ☐ No
PLEASE COMPLETE AND BRING WITH YOU TO YOUR PRE-OP APPOINTMENT!
***To be filled out at 2nd visit only***
Changes in Medical History since previous visit: Yes ☐ No ☐ If yes explain:
Rev. 1/16 PATIENT HISTORY
(PATIENT LABEL)