"*" indicates required fields Patient Name*DOB* MM slash DD slash YYYY Height*_____ Feet _____ InchesWeight*lbsPatient Medical HistoryPlease select any relevant medical history, or indicate "none of the above" in each column:History - Column 1* Aneurism Pulmonary Embolism Hx of Blood Clots/DVT Stroke/TIA Bone or Joint Infections Asthma Gout Emphysema MRSA Infection Lyme Disease Cancer (Specify type below) Epilepsy/Seizures Diabetes I Diabetes II Stomach Ulcer GERD Diverticulitis Celiac Disease Crohn's Disease Rheumatoid Arthritis None of the above History - Column 2* Tuberculosis Pacemaker Heart Attack High Cholesterol Hypertension Congestive Heart Failure Angina (Chest Pain) Atrial Fibrillation Osteoarthritis Osteoprosis Multiple Sclerosis Liver Disease Hepatitis B Hepatitis C Kidney Disease Kidney Stones Migraines Anxiety/Depression HIV/AIDS None of the above Cancer Type*Other Serious Illness or InjuryPlease list any other serious illness or injury you have hadPrevious Hospitalizations/Surgeries*Please select all previous hospitalizations/surgeries Hip Replacement Arthroscopy Knee Knee Replacement Arthroscopy Shoulder Rotator Cuff Repair Upper Extremity Fracture Shoulder Replacement Carpal Tunnel Release Lower Extremity Fracture Heart Surgery Hernia Repair LAP Band/Gastric Bypass Surgery Gallbladder Malignancy/Cancer Mastectomy Lumpectomy Hysterectomy Aortic Bypass/Vascular Surgery Pacemaker Stents Aneurysm (Brain) Surgery Cataract (Eye) Surgery Spine Surgery None of the above Hip Replacement Right Left Arthroscopy Knee Right Left Knee Replacement Right Left Arthroscopy Shoulder Right Left Rotator Cuff Repair Right Left Upper Extremity Fracture Right Left Shoulder Replacement Right Left Carpal Tunnel Release Right Left Lower Extremity Fracture Right Left Spine Surgery Level:Family HistoryHave any of your direct relatives had, or currently have any of the following: (Please check all that apply)Bleeding Problems* Mother Father Sibling None DVT* Mother Father Sibling None Stroke* Mother Father Sibling None Diabetes* Mother Father Sibling None Osteoporosis* Mother Father Sibling None Heart Disease* Mother Father Sibling None Connective Tissue Disorder* Mother Father Sibling None Rheumatoid Arthritis* Mother Father Sibling None Hypertension* Mother Father Sibling None Cancer* Mother Father Sibling None Complications with Anesthesia* Mother Father Sibling None MedicationsPlease list all medications and herbal supplements you take on a regular basis:Do you take any medications or herbal supplements on a regular basis?* Yes No Do you take a prescription blood thinner?* Yes No Medication/Supplement 1Dosage and Frequency (e.g. 20mg, once a day)Medication/Supplement 1Dosage and Frequency 1Medication/Supplement 2Dosage and Frequency 2Medication/Supplement 3Dosage and Frequency 3Medication/Supplement 4Dosage and Frequency 4Medication/Supplement 5Dosage and Frequency 5Medication/Supplement 6Dosage and Frequency 6Medication/Supplement 7Dosage and Frequency 7Medication/Supplement 8Dosage and Frequency 8Medication/Supplement 9Dosage and Frequency 9Medication/Supplement 10Dosage and Frequency 10AllergiesHave you ever had an adverse reaction to anesthesia?* Yes No If yes, what was your reaction?Do you have a Latex allergy?* Yes No Do you have any food or medication allergies?* Yes No Please list Medication and/or food allergiesAllergy 1Reaction 1Allergy 2Reaction 2Allergy 3Reaction 3Allergy 4Reaction 4Allergy 5Reaction 5Social HistoryDo you smoke tobacco, Medical Marijuana, or Vape?* No Former Current Do you consume alcohol?* No Rarely Occasionally Daily Marital Status:* Married Single Divorced Widowed Domestic Parnership Do you live alone?* Yes No Do you exercise regularly?* No Yes Occupation:*Employer:*PhoneThis field is for validation purposes and should be left unchanged.
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