Patient Medical History

Name *
Reason for consult*
Projected surgery date

MesDíaAño
Start
Date of birth*

MesDíaAño
Age*
Sex*
Height *
Weight *
BMI
Email*
Phone number *
Address*
Occupation *
How did you hear about us?
Past medical history

Has any physician ever told you you have any problems with:
Cardiovascular*
Explain
Respiratory/pulmonary *
Explain
Renal (kidneys)*
Explain
Endocrine (hormone imbalance)*
Explain
Neurologic (nervous system)*
Explain
Musculoskeletal*
Explain
If so, do you have imaging on file?

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Hematologic (blood disorders)*
Explain
Have you ever had bleeding/coagulating issues
Allergies*
Explain
Surgeries*
Type / year - complications?
Did you ever have any adverse reaction to anesthesia?*
Explain
Blood transfusions in the past?*
If so, any adverse reactions?
Have you been hospitalized before (other than for surgery)?*
Reason – year – resolved?
What medication do you take? (Type – dose – how long?)
Have you had a physical examination in the past year?*
Do you drink?*
How many drinks per week?
Do you smoke?*
How much per day?
How long have you smoked?
Do you consume any recreational drugs?*
How much per day?
How long have you done it?
Do you consume any non-prescribed medication?*
Medication – dose – how long have you done it?
Are your immunizations up to date?*
Is there anything else you think we should know?
Is your father living?*
Has he been diagnosed with an illness?
Is your mother living?*
Has he been diagnosed with an illness?
How many siblings do you have?
Do they all live?
Has any of them been diagnosed with an illness?
Gynecologic history

Date of last period
Start

MesDíaAño
Fecha
End

MesDíaAño
Fecha
How many total pregnancies have you had?
Of those, how many were: Labors
C-sections:
Miscarriages:
Abortions
Have you had gestational diabetes?
Are you currently on birth control?
Type – dose – duration
Should be Empty:

Past medical history

Gynecologic history

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