Form 20100813 - Patient Information Form Page 2

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NORTH ATLANTA
SURGICAL ASSOCIATES
 congestive heart failure
 circulation problems
Cardiovascular
 heart attack
 pacemaker
 blood clots, phlebitis
 chest pain, angina
 murmur
 free bleeder
 irregular pulse
 rheumatic fever
 hemophilia
 cardiac arrest
 mitral valve prolapse
 bruise easily
 high blood pressure
 anemia
 none
 pneumonia
 sinus problems
Respiratory
 bronchitis
 shortness of breath
 sleep apnea
 chronic cough
 home oxygen therapy
 collapsed lung
 asthma, wheezing
 tracheostomy
 none
 emphysema, COPD
 tuberculosis (TB)
 stroke
 migraine headaches
Neurological
 seizures
 spinal cord injury
 fainting
 paralysis
 numbness or tingling
 none
 head injury
 low blood sugar
 swallowing problems
Gastointestinal
 hiatal hernia, reflux, heartburn
 gall bladder problems
 recent vomiting or diarrhea
 peptic ulcer
 liver disease
 loss of appetite
 bowel disease
 diet, food intolerance
 recent weight gain/loss
 abdominal pain
 hemorrhoids
 ostomy: type_____________________
 hepatitis: type________ year_______
 constipation
 none
 Diabetes
diet  insulin  oral medication
 none
controlled by:
 Thyroid Disease
overactive  underactive
 none
 frequent urine infections
 prostate disease
Genitourinary
 kidney stones
 difficulty with urination
 last prostate check:________________
 difficulty with control
 painful or frequent urination
 sexual problems
 catheter, self catheter
 kidney disease
 none
 blood in urine
 dialysis: type_____________________
Gynecological
Is there any chance you are pregnant?
Date of last mammogram_____________
 No  Yes
Are you pregnant?
Date of last pap smear________________
 No  Yes, # weeks: _______________
 heavy, painful or irregular periods
Date of 1st day of last period__________
 none
 marriage
 abuse (emotional, physical, sexual)
Emotional Health
 domestic violence
 divorce
Do you have any emotional needs, recent
 loss of baby
 death of someone close to you
personal changes, or past history that you
 job loss or new job
 none
would like to make us aware of?
 depression
 psychological/substance abuse therapy
 catastrophic news
as  inpatient  outpatient
 clergy to be called
 dietary
Spiritual/Cultural Needs
 health care treatment concerns
 sacramental needs
Do you have any spiritual, emotional or
 none
cultural needs that you would like to
affected by religious/cultural beliefs
 religious practice/special days
make us aware of?
Any significant health problems not listed above?  No  Yes, explain:________________________________________________
Page 2 of 2
Form 20100813

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