Adult Patient Admission History Page 3
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4XII. Have you ever had, or do you have any of the following? Check only if applicable.
ANESTHESIA HISTORY
NA YES If Yes, Describe
NEUROLOGICAL
NA YES If Yes, Describe
Received Anesthesia
Alzheimer’s/Dementia
Anesthesia Problems
Seizures
Relatives w/anes. problems
Mental Status Changes
Migraines, Headaches, Head Injury
Previous Operations/Hospitalizations
Date
Reason
Neuromuscular Disease
Neurovascular Disease
Sleep Disturbances
Stroke/TIA
Syncope/Fainting
VASCULAR ACCESS
NA YES If Yes, Describe
AV fistula, Hickman, Mediport, Groshong, PICC…
CARDIOVASCULAR
NA YES If Yes, Describe
Chest Pain/Angina
Congestive Heart Failure
ENDOCRINE/METABOLIC
NA YES If Yes, Describe
Phlebitis/Deep Vein
Diabetes/Hypoglycemia
Thrombosis/(Blood Clot in leg)
Edema/Swelling
Pituitary/Adrenal Disease
Hypertension/High BP
Thyroid Disease
Heart Attack (MI)
Murmer/Mitral Valve Prolapse
GASTROINTESTINAL
NA YES If Yes, Describe
Pacemaker/Defibrillator
Change in Bowel Routine
Constipation/Diarrhea
GI Bleed
RESPIRATORY
NA YES If Yes, Describe
Asthma, Bronchitis, COPD
Hemorrhoids
Emphysema, Pneumonia
Fatigue, Night Sweats,
Hiatal Hernia/Reflux
Tuberculosis
Sore Throat, Cough, Cold in last
Duration?
Liver Disease/Hepatitis
2 weeks?
Tobacco Use
Pk/Day:
# of
Nausea/Vomiting
Yrs.
Stopped Tobacco Use:
Ostomy
When:
Smoking Cessation
Pancreatitis
Counseling given
Oxygen Therapy,
Ulcer Disease
Recent Sputum Changes
PATIENT IDENTIFICATION
INOVA HEALTH SYSTEM
ADULT PATIENT ADMISSION HISTORY
Name
Date:
Last,
First
DOB __/__/____
Page 3 of 4
Mo/ Day/
Year
CAT # 81789 / R102904
MR24-00
PKGS OF 100
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