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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