Salem Laser and Surgery Center
1330 Commercial SE
Salem, Oregon 97302
PATIENT HEALTH HISTORY
Patient Name:
Dr.:
Have you had: (Check all that apply)
Have you had:
Yes
No
Heart Attack ☐ Chest Pain ☐ Murmur ☐
Hiatal Hernia
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Congestive Heart Failure ☐
Seizures
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Coronary Artery Disease ☐
Yes
No
Last episode:
Heart Surgery?     If yes, when?
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Stroke / TIA     If yes, when:
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Heart Valve Disease or Rheumatic Fever?
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Parkinsons Disease
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Do you use Nitroglycerin?
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Neuro-muscular problem
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If yes, how frequent?
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☐ Paralysis   ☐ Numbness   ☐ Weakness
Irregular of Fast Heartbeat
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Where
High Blood Pressure
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☐ Hard of hearing     ☐ Deaf
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Pacemaker or Implanted Defibrillator
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Hearing aids:   ☐ Left     ☐ Right
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☐ Asthma     ☐ Emphysema     ☐ Bronchitis
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☐ Anxiety     ☐ Panic attacks
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TB     If yes, when:
☐ Claustrophobia
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Do you use inhalers?
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Do You:
Recent respiratory infection
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Take blood thinners or Aspirin?
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Chronic or current cough
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Use Alcohol     If yes, amount
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Short of breath: ☐ At rest     ☐ With activity
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Smoke     If yes, amount per day
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Do you use oxygen at home?
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If in past, when did you quit
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☐ All the time         ☐ Only at night
Lung surgery: When?   Why?
How much do you Weigh?   Height?
Cancer
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Who is your primary doctor:
Type/Location
Bleeding Tendency
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Diabetes
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Bad reaction to anesthesia
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Controlled by:   ☐ Diet     ☐ Oral agent     ☐ Insulin
☐ Self     ☐ Relative
Advance Directive:       ☐ Yes       ☐ No
Allergies and Reactions: (Including medicine / anesthesia / latex / Iodine)
Current Medications Including "over the counter drugs" and herbal supplements:
Prior Surgeries:
Any other diseases, conditions or major medical problems we should know about:
Signature:
Date:
Reviewed by:
Date:
Time:
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:
Signature:
Date:
Reviewed by:
Date:
Time:
Rev. 1/16       PATIENT HISTORY
(PATIENT LABEL)