PLEASE LIST ANY SURGICAL PROCEDURES OR HOSPITALIZATIONS:
 

WHY ARE YOU HERE?

WHO REFERRED YOU TO SURGICAL ASSOCIATES?

WHO IS YOUR PRIMARY CARE DOCTOR?

YOUR INTERNIST? YOUR CARDIOLOGIST? (IF ANY) ANY OTHER PHYSICIANS?

PROCEDURE/HOSPITALIZATION	WHERE/WHEN	DOCTOR	PROBLEM

(USE ADDITIONAL SPACE AT THE END OF THIS FORM IF NEEDED)

PRESENT MEDICATIONS (Please include prescription and/or over-the-counter medications)

MEDICATION              DOSAGE

ANY ALLERGIES TO ANY MEDICATIONS? NO YES, please describe below what type of allergic reaction.

USE ADDITIONAL SPACE AT THE END OF THIS FORM IF NEEDED
 

SYSTEMS REVIEW (Please circle if you have or have had any of the following)
 

General Recent weight change Fever/chills Fatigue Night sweats Skin and Hair Rashes/sores Skin cancers or melanomas Hair loss Unusual lumps under the skin Endocrine Diabetes Thyroid High blood pressure Ears, Nose & Throat Glasses/contacts Double vision Hearing Loss Persistent ringing in the ears Difficulty swallowing Pain or stiffness in the neck Fullness in the neck or throat Hoarseness or voice change Lungs Shortness of breath Emphysema or chronic bronchitis Asthma or wheezing Congestive heart failure Persistent cough Pneumonia Heart and Blood Vessels Heart attacks Chest pain Heart murmur Heart surgery Irregular heart beat (palpitations) Swelling in feet Phlebitis or blood clots High blood pressure Gastrointestinal Difficulty swallowing Heartburn Hiatal hernia Ulcer disease Jaundice Hepatitis or other liver disorders Colitis Irritable bowel syndrome Crohn's disease Constipation Diarrhea Hemorrhoids/rectal disorders Blood in stool Abdominal pain	Musculoskeletal Arthritis Joint Pain, stiffness or swelling Decreased muscle strength Previous bone disease Osteoporosis Any broken bones Back pain/back surgery Neurological Headaches Dizziness/fainting Weakness or tingling of arms or legs History of any head injury Blood Anemia Blood transfusions If yes, when, how much, and why ___________________ Infections/Immunizations Any serious infection Childhood illnesses: __ measles __ mumps __ chicken pox Last tetanus shot ___________ last flu shot ___________ For women only: Abnormal bleeding or discharge Any gynecological surgery Pain during intercourse Kidney stones Urinary tract infections Sexually transmitted diseases (gonorrhea, syphilis, herpes, venereal warts, AIDS, etc.) Age at time of first menstrual period _________________ Number of pregnancies ___________ Number of live births _____________ Did you breast feed your children? ________ Average, how long ___________________________________________ Last menstrual period _____________________________ Breasts Breast pain NIpple discharge Breasts lumps Previous breast surgery Changes in breast size For men only: Kidney stones Prostate disease Difficulty urinating Urinary tract infections Vasectomy Sexually transmitted diseases (gonorrhea, syphilis, herpes, venereal warts, AIDS, etc.)
IF YOU ANSWER YES TO ANY OF THESE QUESTIONS, PLEASE EXPLAIN.

PLEASE LIST ILLNESSES (for which you see a doctor or take medication)

 
 
 

FAMILY HISTORY: (please indicate if any relatives has, or had)

FAMILY HISTORY OF CANCER: (please indicate if any relative has, or had)

AGE

RELATIONSHIP

AGE

RELATIONSHIP

Hypertension			Breast Cancer
Diabetes			Colon Cancer
Thyroid			Ovarian Cancer
Heart Attack
Please specify any other

SOCIAL HISTORY

WHAT IS YOUR OCCUPATION? RETIRED DISABLED

DO YOU SMOKE? NO YES        HOW MANY PACKS A DAY?   HOW MANY YEARS?

DO YOU DRINK? NO YES BEER ALCOHOL DRINKS PER DAY

DO YOU DRINK COFFEE? NO YES CUPS PER DAY

HAVE YOU EVER USED ANY STREETS DRUGS SUCH AS COCAINE, MARIJUANA, ETC? NO YES, please describe

Patient 
Signature: ___________________________________________ DATE: ____________________