Plastic Surgery medical history form - Via Christi Health

[Pages:3]Via Christi Plastic Surgery & Aesthetics Richard DeSplinter, MD

9211 E. 21st St. | 1947 Founders' Circle 14700 W. St. Teresa Suite 205 Wichita, KS 316.609.4440

Plastic Surgery medical history form

Date: ________________________

MRN (office use only):_________________________

Name (please print clearly): ________________________________________________________________

Date of birth: ________________________ Gender (please circle one): male female

Address: _____________________________________________________________________________

City: ______________________________________ State: _________________ Zip: ________________

Home phone #:________________Cell phone #:__________________Work phone #:________________

Email address: _________________________________________________________________________

How did you hear about us? Website

Family/friend

Newspaper

Magazine

Phone book Physician Referral Other

Employer: __________________________________ Occupation: ________________________________ Reason for visit: ________________________________________________________________________ When did you first notice this? _____________________ How long does it last? _____________________ Does anything make it worse? _____________________ Does anything make it better? _______________

Past medical history: Have you had any of the following health problems in the past?

Cancer

Diabetes

Epilepsy

Hormone imbalance

Spinal Injury

Thyroid condition

Systemic disease

Heart problems Varicose veins

Please list any medical conditions you have or have had below. (E.g. heart disease, diabetes, high blood pressure, stroke, blood clots or heart attack, ulcers, cancer) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Past surgical history Please list and date previous surgical procedures

Procedure

Year

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ Medications (Please include BCP and estrogen replacement therapy.)

Name

Dosage (mg/strength)

Times per day

_____________________________________________________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Medication allergies

Reaction

_____________________________________________________________________________________

_____________________________________________________________________________________ _____________________________________________________________________________________

Have you had an operation where any bleeding or anesthetic complications occurred? Yes No

If yes, please explain: ___________________________________________________________________ Family history Please list any serious conditions that run in your family: _______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Social history: Do you smoke? Yes No If so, maximum packs per day? __________ For how many years? ___________ Do you consume alcohol? Yes No If so, list amount and frequency: ______________________________ _____________________________________________________________________________________

Medical history form -- review of systems

Do you now, or have you had any problems related to the following body systems? Please check yes or no, and explain in the space provided.

General symptoms: Fever Chills Weight loss Vision / Eyes: Blurring Doubling Blindness

Yes No

Allergy / Immune:

Hay fever Drug allergy Latex Other Neurologic: Tremors Dizziness Numbness Stroke TIA Gastrointestinal: Abdominal pain Nausea Vomiting Heartburn Appetite loss Bloody stool Heart: Chest pain Heart attack Palpitations Passing out Psychological: Are you satisfied with life? Are you depressed? Have you been suicidal? Physician use: (Comments / Notes)

Comments

Skin: Rash Boils Itching Musculoskeletal Joint pain Neck pain Back pain Ear / Nose / Throat: Infection Sinus problem Snoring

Genitourinary: Incontinence Painful void Frequency Difficulty

Respiratory: Wheezing Persistent cough Short of breath Winded easily

Yes No

Yes No

Blood / Lymph: Easy bruising Bleeding Blood clots Swollen glands Comments

Comments

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