Hospitalization & Surgical History Form
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1Today’s Date _____________________ Patient Name _____________________________________________ DOB __________________
Hospitalization & Surgical History – List all hospital admissions and operations you have had.
Reason for Hospitalization/Surgery
Year
1 __________________________________________________________________________
____________________
2 __________________________________________________________________________
____________________
3 __________________________________________________________________________
____________________
4 __________________________________________________________________________
____________________
5 __________________________________________________________________________
____________________
6 __________________________________________________________________________
____________________
7 __________________________________________________________________________
____________________
8 __________________________________________________________________________
____________________
9 __________________________________________________________________________
____________________
10 __________________________________________________________________________
____________________
o Yes o No Did you have any problems with anesthesia? If yes, please describe.
____________________________________________________________________________________________________
Social History
o Yes o No Do you currently smoke or use other tobacco products? If yes, how many per day? ___________________________
o Yes o No Have you smoked or used other tobacco products in the past? If yes, how many per day? _____________________
How many years since you last smoked? ________________________________________________________________
o Yes o No Do you drink caffeinated beverages? If yes, what type, how often, how much? _______________________________
o Yes o No Do you drink alcohol? If yes, what type, how often, how much? ____________________________________________
o Yes o No Do you exercise regularly? If yes, what type? ____________________________________________________________
How often and how long? _____________________________________________________________________________
Family Medical History – Check the box next to any medical condition below that has affected any of your immediate family
members (parents, brothers, sisters), state your relationship and their age at onset.
Relationship
Age at onset
o High Blood Pressure
____________________________________________
_______________________
o High Cholesterol
____________________________________________
_______________________
o Heart Disease
____________________________________________
_______________________
o Stroke
____________________________________________
_______________________
o Migraines
____________________________________________
_______________________
o Seizures/Convulsions
____________________________________________
_______________________
o Diabetes
____________________________________________
_______________________
_______________________
o Bleeding/Blood-clotting Disorder
____________________________________________
_______________________
o Allergies
____________________________________________
_______________________
o Asthma
____________________________________________
_______________________
o Thyroid Problems
____________________________________________
_______________________
o Osteoporosis
____________________________________________
_______________________
o Psychiatric Disorder/Mental Illness
____________________________________________
_______________________
o Alzheimer’s/Dementia
____________________________________________
_______________________
o Cancer - type:
____________________________________________
_______________________
o Other:
____________________________________________
HOSPITALIZATION, SOCIAL, &
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FAMILY HISTORIES
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