Kimberley Goh, M.D.
GRAND STRAND PLASTIC & RECONSTRUCTIVE SURGERY CENTER, P.A.PATIENT’S PERSONAL MEDICAL HISTORY FORMFULL NAME: ________________________ REASON FOR VISIT:______________________________________________SURGICAL HISTORYPatient Past Surgeries/Hospitalizations (if none, please print none)Surgery/HospitalizationDateAnesthesia ComplicationsNotes12345678910PAST MEDICAL HISTORYYesDetailsYesDetailsNo significant past medical historyINFECTIOUS DISEASEAUTOIMMUNELyme DiseaseLupusHepatitisSjogren’s DiseaseHistory of MRSA InfectionRheumatoid ArthritisHIV/AIDSSclerodermaTuberculosisOther AutoimmuneOther Infectious DiseaseFibromyalgiaNEUROLOGICCARDIOVASCULARAlzheimer’s DiseaseHigh Blood PressureStroke/TIAHeart DiseaseConvulsions/SeizuresHeart MurmurFainting/WeaknessChest Pain/TightnessMSIrregular HeartbeatParkinson’s DiseasePeripheral Vascular DiseasePeripheral NeuropathyVaricose Veins (Venous Insufficiency)Psychiatric CareOther CardioOther Neurologic RelatedCANCER HISTORYOPHTHALMOLOGICBreast CancerDouble VisionSkin CancerDry EyesOther CancerCataractsCUTANEOUSGlaucomaAcneBlindness/Loss of VisionEczema/PsoriasisContact LensesSkin DiseaseOther OphthalmicENDOCRINEOther Eye RelatedDiabetesOROPHARYNGEALThyroid DisorderAirway obstructionPolycystic OvarySinus InfectionsPituitary or AdrenalHay FeverOther EndocrineFever BlistersGASTROINTESTINALLoss of HearingUlcersOther ENT RelatedHiatal HerniaPULMONARYJaundiceBronchitis Other GIPneumoniaGENITOURINARYShortness of BreathKidney StonesAsthmaStress IncontinenceCOPD/EmphysemaUrinary Tract InfectionOther PulmonaryGynecologic IssuesTRAUMA/MISCOther GUHistory of Trauma or InjuryHEMATOLOGIC/BLOODRadiation Treatment or ExposureLeukemia/LymphomaEnvironmental ExposuresAnemiaOTHER IMPORTANT ISSUES:PolycythemiaBleeding Disorder Clotting DisorderOther HematologicALLERGIES AND MEDICATIONSALLERGIES: If none please indicate NKDACURRENT MEDICATIONS: (Please PRINT and list all current prescription medications and over-the-counter medication or supplements you take on a regular basis) Please indicate N/A if not applicableAllergyReactionNotesMedicationDosage (Amount)Prescribed by: FAMILY HISTORYCheck if YesAfflicted Family MemberNotesNo Contributing Family HistoryAbnormal BleedingAbnormal ClottingAdoptedAnesthesia ProblemsAutoimmune DisordersBreast CancerEndocrine DiseaseHemophiliaMalignant HypothermiaOther CancerOvarian CancerSkin CancerSkin DiseaseUnknownvonWillebrandSOCIAL HISTORY (check appropriate boxes)ALCOHOL HIGH RISK FACTORSDenies alcohol useDenies high risk factorsAdmits alcohol use sociallyAdmits high risk factorsAdmits alcohol use dailyAdmits to hx of alcoholismILLEGAL DRUGSSMOKING STATUS:Denies using illegal drugsSmoking StatusYes NoAdmits to using illegal drugsStartedAdmits to history of drug abuseEndedMISCELLANEOUSAdverse Reactions or Sickness From:YesNoNotesAspirin productsNovacaine, Xylocaine, or other local anestheticsAdhesive tapesIodineAntibioticsLatex rubberIn the past six months have you taken:SteroidsBlood pressure medicineDiet drugs/herbsAccutaneHigh dose vitaminsGeneral:Scar easilyCold sores/fever blistersPERSONAL SOCIAL HISTORYMARTIAL STATUS:YESNOTES:SingleEngagedMarriedSeparatedDivorcedWidowedPartnerN/A or withheldWORK HISTORY:EmployedCurrently UnemployedRetiredDisabledPart time workStudentHomemakerPertinent hobbies or activitiesStatus withheldFEMALE QUESTIONSYesNoN/ANotesHistory of Breast DiseaseHave you nursed (breast fed) or are you nursing?Are you or do you think you may be pregnant?Family History of Breast/Ovarian CancerOther InfoMORE FEMALE QUESTIONSNotesBREAST SURGERY PATIENTSNotesDate of last menstrual period?What is your current bra and cup size?Number of pregnancies?What size do you want?Number of live births?Are you interested in a breast lift?Last mammogram?Are you interested in breast reduction?HEIGHT/ WEIGHT/BLOOD PRESSUREPlease indicate any additional pertinent health information below:Height (inches)Weight (lbs)Systolic Blood Pressure (top)Diastolic Blood Pressure (bottom)I understand that the above information and any explanations on the form are important for my care (or the patient’s if filled out by someone other than the patient) during and after surgery. I therefore certify that the answers and explanations are true and correct to the best of my knowledge.________________________________________________ ____________________________________________________(Signature of Patient) (Signature Parent/Guardian)_________________________________ _______________________________Date Date ................
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