Patient Information Form

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Patient Name: ___________________________________
Chart #: _______________
Date of Birth: _______________
Referring Physician: ______________________________ Family Physician________________________________
Height: _____________
Weight: _____________
Body Mass Index (BMI): ___________________
YES NO PAST MEDICAL HISTORY:
YES
NO PAST MEDICAL HISTORY:
(circle any that apply)
(circle any that apply)
_____ _____
heart disease
_____ _____
GI ulcer disease / hiatal hernia / gastric reflux
_____ _____
high blood pressure
_____ _____
IBS / Crohns / ulcerative colitis / diverticulosis
_____ _____
congestive heart failure
_____ _____
kidney disease/stones
_____ _____
heart murmur
_____ _____
hepatitis/tuberculosis / HIV/AIDS
_____ _____
arrhythmia / atrial fibrillation
_____ _____
history of cancer (location: _______________ )
_____ _____
previous heart attack (MI) or stroke (CVA or TIA)
_____ _____
seizure disorder / neurological disorder
_____ _____
history of blood clot (DVT or PE) / phlebitis / varicose veins
_____ _____
glaucoma
_____ _____
bleeding / clotting disorder
_____ _____
alcohol use / abuse / addiction
_____ _____
high cholesterol
_____ _____
prescription drug abuse / addiction
_____ _____
obesity / eating disorder
_____ _____
recreational drug use / abuse / addiction
_____ _____
diabetes mellitus
_____ _____
depression / anxiety / psychiatric illness
_____ _____
thyroid disease
_____ _____
fibromyalgia
_____ _____
asthma / emphysema / COPD
_____ _____
osteoarthritis / rheumatoid arthritis / lupus
_____ _____
MRSA / VRE
_____ _____
osteoporosis / postmenopausal
_____ _____
Bi-Polar
_____ _____
seasonal allergies
MEDICATIONS & DOSAGES (including vitamins and herbal supplements): ____________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Pharmacy Name and Phone Number:_______________________________________________________________
ALLERGIES (medications, foods, iodine, contrast dye, latex, adhesive tape, etc): ______________________________________
SOCIAL HISTORY:
Do you smoke tobacco? _____ How many packs?__________ Chew Tobacco? _____ How much? _____ How many years?______
Do you consume alcohol?____________ How much?___________________ How often?_____________________
Marital status:____________________ Are you pregnant? ______________ Children?_______________________
Occupation:_____________________ Hobbies:_____________________________________________________
YES NO FAMILY HISTORY: Has anyone in your family:
YES
NO
_____ _____
Had a tendency to bleed excessively?
_____ _____
Had a blood clot?
_____ _____
Had unusual reactions to anesthesia?
_____ _____
Been diagnosed with cancer?
_____ _____
Other significant health problems? Explain: ______________________________________________________________
What operations have you had and when?: ___________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please list other hospitalizations and reasons for admission: _______________________________________________
YES NO REVIEW OF SYSTEMS:
YES
NO REVIEW OF SYSTEMS:
(circle all that apply)
(circle all that apply)
_____ _____
constitutional - unexplained fever/weight loss/
_____ _____
constipation / diarrhea / bloating
night sweats / chills
_____ _____
blood in stool
_____ _____
fatigue
_____ _____
abdominal pain
_____ _____
muscle / joint pain (location: __________________)
_____ _____
cough
_____ _____
easy bruisability
_____ _____
shortness of breath / wheezing
_____ _____
skin rash
_____ _____
chest pain / palpitations
_____ _____
oral ulcers
_____ _____
loss of bowel control / loss of bladder control
_____ _____
visual or hearing changes
_____ _____
leg edema / swelling
_____ _____
headaches
_____ _____
numbness / tingling / weakness (arms or legs)
_____ _____
difficulty swallowing
_____ _____
other _______________________________
PATIENT SIGNATURE: ________________________________________________ Date: _________________
PHYSICIAN SIGNATURE: _____________________________________________ Date: _________________
Revised June 2013
COS/049

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