Adult Health History Form For New Patients Page 3
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4SURGICAL HISTORY:
[ ] None
Please check off any procedures or surgeries..
√
SURGICAL PROCEDURE
YEAR
COMMENTS
Hernia Repair
Appendectomy (appendix removal)
Back/Neck (Spine) Surgery
Biopsy (Location)
Breast Biopsy/Surgery
Circle: Right/Left/Both)
(
Cataract
Circle: Right/Left/Both)
(
Colonoscopy/Sigmoidoscopy
EGD (Stomach Endoscopy)
Gastric band/bypass (Weight Loss Surgery)
Gallbladder Removal (Circle: Open or Laparoscopic)
Coronary Bypass or Stent
Heart Surgery (Other than Coronary Bypass)
Hip Surgery
Circle: Right/Left/Both)
(
Knee Surgery
Circle: Right/Left/Both)
(
Hysterectomy (Total or Partial)
Ovary Removal or Ligation (“Tubal”)
Vasectomy
Other (List)
Other (List)
FAMILY HISTORY –
Please indicate which relative has had the following diseases (Parents and siblings are the most important)
ADOPTED? YES or NO (please circle) If yes and you do not know your family history, you may skip this section.
RELATIONSHIP
√
DISEASE
COMMENTS
(Father, Mother, Children,
Grandparents, Aunt/Uncles, Other)
No significant history known
Alcoholism/Drug abuse
Alzheimer’s Dementia
Asthma
Autoimmune Disease
Bleeding or Clotting Disorder
Cancer _____________
Cancer _____________
Colon Polyp
Coronary Artery Disease (Heart Attack, Angina)
Age of Onset______
Depression/Suicide/Anxiety
Diabetes – Type 1 (childhood onset)
Diabetes – Type 2 (adult onset)
Emphysema (COPD)
Genetic Disorder (explain)
Heart Failure (CHF)
Hepatitis ( A, B, or C)
High Blood Pressure (Hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Kidney Disease
Migraine Headaches
Osteoporosis
Stroke
Other (please list)
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