Surgical Services History Form printable pdf download

SURGICAL SERVICES HISTORY

DATE: ____________________

NAME: ____________________________________________

DOB ______________

AGE: ______

CC: Why are you here today? __________________________________________________________________________________

Date (s): _______________________________________________

A. PERSONAL MEDICAL HISTORY

D. GYNECOLOGY HISTORY

Please  ‘y” for yes and “n” for no if you have ever had or

needed treatment for any of the following:

Y N

  Uterine fibroids or other uterine abnormality

Y N

  Diabetes (high blood sugar) with complications

History of sexually transmitted disease.

 

  Seizures

If so, please specify:



Lung problems, including asthma

Pelvic Inflammatory Disease

 

Last attack? ___________________________

Infection of uterus following an abortion, miscarriage, or

 

Snoring or sleep apnea (short periods of time where you

delivery? If yes, when?

 

stop breathing while you are asleep)

How long have you been with your sex partner?

  High Blood Pressure

How many partners have you had in the last 3 months?

  Heart problems of any kind

Does your partner(s) have sex with anyone other than you?

  Anemia. What type? ____________________________

 Yes  No

Hemorrhagic disorders (blood won’t clot properly,

E. SURGICAL HISTORY

 

leading to too much bleeding)

Y N

  Myomectomy (Removal of fibroids)

Blood clotting disorders e.g. Factor V Leiden, protein

 



disorders, or other genetic blood disorders

LEEP – for treatment of precancerous condition of cervix

  Blood clots (head, leg, chest)



Tubal ligation (Tubes tied)

Taken, or taking now, anticoagulant (blood thinners)



Surgery for ectopic pregnancy

 

such as Heparin, Warfarin, Coumadin or Lovenox



Other (Specify)

  Stroke or stroke like problems

F. MEDICATIONS/ALLERGIES

Migraine syndrome w/aura (w/ or w/o headache), H/A

Are you taking any medications? If yes, please list

 

w/speech difficulties, numbness, “pins/needles” or rapid

onset of transient one‐sided blindness

  Psychiatric Illness _______________________________

  HIV/AIDS

  Cancer. If yes, where? _____________________

 No

Are you allergic to ANY MEDICATION?  Yes

  Breast disease

If yes: what medication?

  Liver problems, including hepatitis

  Gallbladder problems

  Kidney disease

Have you ever had a reaction to any drug/medication, sedation,

  Bladder disease or infection

local anesthesia, general anesthesia, Betadine, latex, copper or

 No

  Adrenal gland problems

other substances?  Yes

  Elevated blood fats or cholesterol

If yes: what?

  Anorexia/Bulimia

  Lupus (SLE)

G. SOCIAL HISTORY

  Rheumatoid arthritis

Do you smoke cigarettes? Yes No If yes, how many?

  Osteoporosis

Do you drink alcohol?  Yes No

B. FAMILY HISTORY

If yes, when was the last time you had an alcoholic beverage?

Y N

_______________________________

  Mother/Sister – Heart attack/stroke before age 65

Do you use street drugs?  Yes  No

  Father/Brother – Heart attack/stroke before age 65

If so, what kind do you use and when was the last time you took

  Parent/Sibling with history of blood clots

any?

  Mother/Sister – History of breast cancer

Do you feel that your partner is abusive?

C. OBSTETRIC HISTORY



# of times pregnant (including this pregnancy) _______

Yes, physically abusive. Do you feel like you’re in danger



# of deliveries ______

Date(s):___________________

 No

now or in the near future?  Yes

# of C‐sections ______

Date(s):___________________



Yes, emotionally abusive.

# of vaginal deliveries ______

Date(s):___________________

Does your partner try to control your birth control

# of elective abortions ______

Date(s):___________________



method or choices about pregnancy?

# of miscarriages ______

Date(s):___________________

 Molar pregnancy

Date(s):___________________

PLEASE TURN PAGE OVER

 Ectopic pregnancy

Date(s):___________________

 History of heavy bleeding after delivery

Place Patient Label Here

AB108E – 3/15

Surgical Services History Form

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