Form 20100813 - Patient Information Form

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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

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