Adult Health History Page 5
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9N O R T H E R N N E V A D A
HOPES
your partner in health.
Coronary Bypass
Coronary Stent
EGD (Stomach Endoscopy)
Cataract
Gallbladder Removal
Circle: Laparoscopic
Heart Surgery (other than coronary bypass)
Hip Surgery
Circle: Right Left Both
Hysterectomy (total, including ovaries)
Circle: Laparoscopic Vaginal
Abdominal
Hysterectomy (partial, ovaries left)
Circle: Laparoscopic
Vaginal
Abdominal
SURGICAL HISTORY
Knee Surgery
Continued: Surgical
Circle: Right Left Both
No
Yes
Year
LEEP (Cervix Surgery)
Procedure
Knee Surgery
Neck Surgery
LEEP (Cervix Surgery)
Ovary Ligation (“Tubal”)
Neck Surgery
Ovary Removal
Circle: Right Left Both
Ovary Ligation (“Tubal”)
Vasectomy
Ovary Removal
Sigmoidscopy
Vasectomy
Sinus Surgery
Sigmoidscopy
Other (list)
Sinus Surgery
Other (list)
Are you adopted?
Yes* No
*If yes, and you do NOT know your family history, please skip to section “Other Health Issues”.
DISEASE
OTHER
COMMENTS
RELATIVES
No significant history known
Alcohol / Drug abuse
Allergic Disorder
Cancer
Diabetes
Gastrointestinal Disorder
Heart Disease
Hypertension
Kidney Disease
Mental Illness
Migraine Headache
Myocardial Disorder
Respiratory Disorder
Seizure Disorder
Stroke Syndrome
Tuberculosis
Page 5 of 7
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