General Surgery PATIENT HISTORY FORM

General Surgery PATIENT HISTORY FORM

Name: __________________________________ DOB: ___________ Age: _______ Date: _______________

Referring Doctor: _______________________ Chief Complaint:_____________________________________

Vital Signs: Temp: _________ HR: _________ BP: _________ RR: _________ Ht: _________ Wt: _________

Medication Allergies: ________________________ ________________________

__________________________ __________________________

_________________________ _________________________

Medication

Dose

Frequency

Medication

Dose Frequency

Social History:

Occupation:___________________________ Marital Status: Single Married Divorced Widowed

Tobacco Use:

No

Yes (If yes, # of packs/day _______ # years _______)

Caffeine Use:

No

Yes (If yes, check all that apply: Coffee Tea Soda)

Alcoholic beverage consumption: No Yes (If yes, how much and often_________________________)

Medical History:

HTN Heart Disease Diabetes Stroke Anxiety Depression Asthma GERD

Cancer Other: _____________________________________________________________________

Surgical History:

Appendectomy Cholecystectomy Thyroidectomy Hemorrhoidectomy Mammogram

Hysterectomy Breast Surgery Tubal litigation Colonoscopy

Hernia Repair (location/type) ____________________________________

Other:_______________________________________________________________________________

Family History:

Mother Father Sister Brother Grandfather Grandmother Aunt Uncle

Diabetes

Heart Disease

HTN

Cancer

Other

Please describe any additional problem/concerns which you think the Physician should be made aware of: ___

_____________________________________________________________________________________

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