Patient Name* DOB* MM slash DD slash YYYY Height* _____ Feet _____ InchesWeight*lbsPatient Medical HistoryHistory - 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 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 Cancer Type* Other Serious Illness or Injury Please list any other serious illness or injury you have hadPrevious Hospitalizations/SurgeriesPlease 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 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 DVT Mother Father Sibling Stroke Mother Father Sibling Diabetes Mother Father Sibling Osteoporosis Mother Father Sibling Heart Disease Mother Father Sibling Connective Tissue Disorder Mother Father Sibling Rheumatoid Arthritis Mother Father Sibling Hypertension Mother Father Sibling Cancer Mother Father Sibling Complications with Anesthesia Mother Father Sibling 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 1 Dosage and Frequency 1 Medication/Supplement 2 Dosage and Frequency 2 Medication/Supplement 3 Dosage and Frequency 3 Medication/Supplement 4 Dosage and Frequency 4 Medication/Supplement 5 Dosage and Frequency 5 AllergiesHave 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 1 Reaction 1 Allergy 2 Reaction 2 Allergy 3 Reaction 3 Allergy 4 Reaction 4 Allergy 5 Reaction 5 Social 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: NameThis field is for validation purposes and should be left unchanged.