Date of Birth Height Weight Dominant Hand R L Ambidextrous Family Doctor Referring Doctor MEDICAL HISTORY150Check any that applyAdverse Reaction toAnesthesiaBlood ClotsDepre ID: 885468
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1 AppointmentDate: / Name:
AppointmentDate: / Name: Date of Birth: / Height: _______Weight: _______Dominant Hand: R / L/ Ambidextrous Family Doctor: ___________________________________ Referring Doctor: ____________________________________ MEDICAL HISTORY – Check any that apply Adverse Reaction to Anesthesia Blood Clots Depression Heart Attack Jaundice Thyroid Anemia Bronchitis Diabetes Heart Failure Pacemaker Tuberculosis Anxiety Cancer (type? ________ Dialysis Hepatitis Pneumonia Ulcers Arthritis Chest Pain Easy Bleeding High Blood Pressure Rheumatic Fever Other_________ Asthma / Emphysema COPD Gout Home Oxygen Seizures/ Epilepsy Other_________ Back Injury CPAP Headaches/ Migraines Irregular Heart Rate Strokes Other_________ SURGICAL HISTORY/HOSPITALIZATIONS ____________ __________ / year: _____ ____________ __________ / year: _____ ____________ __________ / year: _____ ______________________/ year:_________________________/ year:_____ ______________________/ year:_____ ____________ __________ / year: _____ ____________ __________ / year: _____ ____________ __________ / year: _____ FAMILY MEDICAL HISTORY - Among Parents, Siblings and Children CONDITION RELATIONSHIP CONDITION RELATIONSHIP Cancer (specify type) Joint Problems Diabetes Kidney Trouble Seizures Thyroid Headaches Other____________ Heart Trouble FAMILY/SUPPORT SYSTEM HABITS (Check any that apply) ALLERGIES (TO MEDICATIONS & NONMEDICATIONS) Married Single Widowed Separated Divorced Committed Significant Other Do you have children? YES NO Do you live alone? YES NO Have help at home?YES NO Occupation:________________________ Hobbies:___________________________ ___________________________________ Never aSmoker Former Smoker: Year quit? ___________________ Current Every Day Smoker: How much? _________ Chewing NicotineContaining Substances: If yes, hat & how much? ___________________ Alcohol: How much? _______________________ Caffeine: ow much? ______________________ Recreational Drugs_____________________ _________________/Reaction __________ _________________/Reaction__________ _________________/Reaction__________ _________________/Reaction__________ _________________/Reaction__________ _________________/Reaction__________ Allergy to Latex Reaction__________ Allergy to Iodine? Reaction___________ LIST CURRENT MEDICATIONS,MEDICINAL MARIJUANA,VITAMINS, & HERBAL SUPPLEMENTSInclude strength & dosage for each Preferred Language:_______________________Race: American Indian or Alaska NativeEthnicity: Hispanic or Latino Asian NonHispanic or NonLatino Black or African American Unknown Native Hawaiian or Other Pacific Islander Declined Unknown White eclined Other ________________________ *Preferred Pharmacy: _________________________ *Preferred Pharmacy Location: ____________________________IF ADDITIONAL SPACEIS NEEDEDFOR RESPONSES, PLEASE USE OTHER SIDE OF FORM MRN # __________ Provider#: ___________ Patient Portal: Information provided DeclinedClinical Summary: Print Portal Declined