Comprehensive Patient History Form
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4Comprehensive Patient History Form
Date:___________________________
Name:___________________________________________________ D.O.B.__________________________
Past Medical History: (check all that apply)
☐ Acid Reflux
☐ Cataracts
☐ Heart disease
☐ Migraines
☐ Alcohol or Drug Problem
☐ Colitis/Crohns
☐ Heart valve problems
☐ Mental Health Diagnosis
☐ Allergy problems
☐ Chronic pain
☐ Hernia
☐ MRSA
☐ Anemia
☐ Depression, Anxiety ☐ High blood pressure
☐ Osteoporosis
☐ Artery/Vein problems
☐ Diabetes
☐ High cholesterol
☐ Recurrent skin infections
☐ Arthritis
☐ Esophagitis, ulcers ☐ HIV
☐ Recurrent UTI
☐ Asthma
☐ Fractures
☐ Irritable bowel
☐ Seizures
☐ Autoimmune disease
☐ Gallstones
☐ Kidney disease
☐ Sexually transmitted
Infections
☐ Bleeding problems
☐ Glaucoma
☐ Kidney stones
☐ Sleep Apnea
☐ Blood clots
☐ Gout
☐ Liver disease/Hepatitis
☐ Stroke
☐ Cancer
☐ Headaches
☐ Lung disease
☐ TB
☐ Thyroid diseases
Other diseases not listed above:________________________________________________________________________
Hospitalizations/Significant injuries:____________________________________________________________________
__________________________________________________________________________________________________
Surgery/Procedures History: (check all that apply)
☐ Appendix
☐ Heart Surgery
☐ Joint replacement/Orthopedic surgery
☐ Bladder Suspension
☐ Bypass
☐ Kidney surgery
☐ Blood vessel surgery
☐ Heart valve surgery
☐ Organ Transplant
☐ Arteries
☐ Angioplasty (balloon)
☐ Prostate surgery
☐ Veins
☐ Stents
☐ Thyroidectomy
☐ Colon/Rectal surgery
☐ Pacemaker
☐ Sinus surgery
☐ Dental surgery
☐ Hysterectomy
☐ Tonsils and/or adenoids
☐ Eye surgery
☐ Complete ☐ Partial
☐ Tubal Ligation
☐ Gallbladder
☐ Hernia
☐ Vasectomy
Other surgery not listed above:_________________________________________________________________________
☐ Previous reaction to anesthesia: (explain) _____________________________________________________________
__________________________________________________________________________________________________
Please list the names of other practitioners you have or are currently seeing:_____________________________________
__________________________________________________________________________________________________
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Revised 12.01.2016
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