NORTH ATLANTA
SURGICAL ASSOCIATES
Date__________________ Name______________________________________________ Age_____ Height_____ Weight _____
Reason for coming to the doctor __________________________________________________________________________________
Person(s) to notify in case of emergency
Name____________________________________ Relationship_____________ Home #______________ Work # _______________
Name____________________________________ Relationship_____________ Home #______________ Work # _______________
Name____________________________________ Relationship_____________ Home #______________ Work # _______________
Allergies and reactions: None or list: _____________________________________________________________________________
List all medications you take:
Medication
Dose/how often
Last dose
Medication
Dose/how often
Last dose
List all previous operations/therapy/procedures/radiation or chemotherapy/central line placement
Operation/therapy/procedure
Anesthesia
Complications
Year
Any religious beliefs affection health care (eg: blood transfusions) No Yes: Explain _____________________________________
Have you or a family member had any serious problems with operations or anesthetics? No Yes: Explain ___________________
_____________________________________________________________________________________________________________
Family medical history: Heart disease Cancer Diabetes Other _________________________________________ None
Primary/regular physician:________________________________________ Phone_________________ Date last seen ___________
Specialist (eg: cardiologist) _______________________________________________________________________________________
Check if you have ever had any of the following:
Habits None
tobacco: type_____________________________ amount/packs per day___________ # of years_____ if stopped when_______
alcohol use: amount____________________________ how often_______________________ time last use_________________
recreational or illegal drug use: type_____________________ amount___________________ time last use_________________
caffeine use: daily amount____________________________________________________________________________________
exercise: type_______________________________________________ how often______________________________________
Oral
General
Vision & Hearing
Musculoskeletal
Skin
Notes
dentures
HIV / AIDS
contacts,
back/neck pain
current bruises,
STAFF USE ONLY
cancer (site:
cane, walker,
Pediatric/Adolescent
(upper/lower)
glasses
rash
teeth missing,
artificial/glass
current burns
__________)
crutches
Questionnaire <=17yr
transfusion
leg cramping
current
loose, chipped
eye
TMJ problems
glaucoma
artificial arm/leg
reaction
wounds, sores,
caps, crown,
sickle cell
cataracts
muscles weak
ulcers
hearing aid
arthritis
problems with
bonding
disease
bridge
None
hard of hearing,
None
tape, type:
(permanent,
deaf
_____________
None
None
removable)
None
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Form 20100813