Medical History Form

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Central Texas Surgical Associates
Medical History Form
Name______________________________________________________________________
Reason for consultation ______________________________________________________
Referring physician ____________________ Primary care physician_________________
Past Medical History
Check all that apply and list details/diagnoses
Myocardial Infarction
Diabetes
High Blood Pressure
Emphysema
Irregular Heartbeat
High Cholesterol
Thyroid Problems
Asthma
Stroke
Coagulation Disorder
Heart Failure
(you may take Plavix or Coumadin for)
Sleep Apnea
Cancer _________________________________________________
Other Medical Problems and details:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies,
birth control pills, herbs, aspirin or blood thinners:
Times
Times
Medication
Dose
Medication
Dose
per day
per day
SURGICAL HISTORY: Including Defibrillators, Pacemakers or Stents
Operation
Date
Operation
Date
1

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