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					                                                                             Patient Name: ____________________
                                                                                      DOB: ____________________




                                             Medical Health History
This form is to help the physician become familiar with your health history. The information is CONFIDENTIAL
and will be included on your medical record. Please complete the form before your first appointment and bring
with you. If you have any questions or need assistance in completing the form, please call 317-923-7211.

Name (Last, First, Middle Initial)                     Male         Birthdate        Age      Social Security No.
                                                                    (mm/dd/yr)
                                                       Female
Address (Street, City, State, Zip Code)                Marital Status    Single        Married Separated
                                                                         Divorced      Widowed
                                                       Contact Info (Please include area code)
                                                       Home phone:______________________________

                                                       Work phone:_______________________________

                                                       Mobile phone:______________________________

                                                       FAX:_____________________________________
Name of Person to Notify in Case of Emergency
                                                       Email:____________________________________
__________________________________                     May we leave a message for you on an answering machine?
Address (Street, City, State, Zip Code)                  Yes       No

                                                       May we send you patient information by email?
                                                         Yes      No

________________________________                       How would you prefer to be contacted?
Relationship                     Telephone               Home phone      Work phone      Mobile phone
                                                         Email           FAX

Patient Employer                                       Alternate contact information
                                                       (Indicate if you would like to be contacted at an alternate
Name:_______________________________________           phone number or email)

Address:_____________________________________          Phone:__________________________________________

City: ___________________State______Zip:________       Email:___________________________________________

Phone No.:___________________________________          Primary Language:_________________________________

                               Please list all of the doctors involved in your care
                      Name                         Address                                   Telephone
Family Doctor


Referring Doctor




                                                                                                                     1
                                                                 Patient Name: ____________________
                                                                          DOB: ____________________

                                             Allergies

Do you have any ALLERGIES to medicines, food, x-ray dyes, chemicals, etc.?   No      Yes
Are you ALLERGIC to Latex?  No     Yes

Allergy                 Reaction                Allergy              Reaction
1.
2.
3.
4.
5.


                                     Medications Medications
                                          Medications
Please list ANY Prescribed, Over the Counter, Herbal Medicines, Vitamins, and Dietary
Supplements that you are taking along with the amount of the medication and how many times a
day you take the medication
Where do you obtain your medications?     Mail order       Pharmacy
Pharmacy Name:______________________Location:_____________ Telephone No.___________
May we call your Pharmacy?    Yes       No

Name of Drug                           Amount      How Often                 Why do you take it?




                                                                                                      2
                                                                       Patient Name: ____________________
                                                                                DOB: ____________________


                                 History of the Present Illness

Please describe the reason you are seeing the surgeon:
_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________
How long have you had this problem? _______________________________________________________

What are your main symptoms? ____________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Has the problem worsened since it first appeared?      No      Yes Describe:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Have you had any of the following with your problem?        Bleeding      Drainage      Pain      Fever

  Other:_________________________________________________________________________________________

Have you had any treatment for this problem?    No       Yes    Describe:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What diagnostic tests have you had to evaluate the problem?

  CT Scan:_______________________
  MRI:___________________________
  Ultrasound:_____________________
  HIDA Scan:_____________________
  Upper GI Series (barium swallow)
  Upper GI Endoscopy (EGD – scope)
  pH or Bravo probe testing to measure acid over 24 to 48 hours
  Esophageal Manometry/Motility ( probe to measure swallowing strength)
  Colonoscopy
  Sigmoidoscopy
  Biopsy:_________________________
  ________________________________
  ________________________________
  ________________________________



                                                                                                            3
                                                                          Patient Name: ____________________
                                                                                   DOB: ____________________



                                               Family History

                   Please indicate if a family member has/had any of the following
                                Father         Mother           Sibling           Grandparent    Children
Alcoholism
Bleeding Disorder
Breast Cancer
Colon Cancer
Uterine Cancer
Cancer (type)
Diabetes
Heart disease
High blood pressure
Kidney Disease
Lung Disease
Mental Illness
Seizures
Sudden Death
Other:



           Current Age
           Age of Death
           Cause of Death


                                               Social History


Spouse/Significant Other Name:__________________________________________________________

Occupation or Profession:_______________________________________________________________

Any travel out of the country in the last 12 months?     No       Yes Where:_____________________

Do you exercise regularly?      No       Yes What Type?______________________________________

Height:______________         Weight:_________________

 Substances                               No      Yes   Daily Amount           When Did You     When Did You
                                                        Packs/day              Start?           Stop?
 Cigarettes
 Cigars
 Pipes
 Chewing tobacco
 Alcohol
 Caffeine
 Cocaine
 Marijuana
 Heroin
 Methamphetamine
 Narcotics
 Sedatives
                                                                                                               4
                                                                       Patient Name: ____________________
                                                                                DOB: ____________________


                                           Health History


              Check  the health problems you have now or had in the past
Health Problem                          Yes Comments
General
 Fever                                      Highest Fever:______
 Chills
 Night sweats
 Weight loss                                How much? ______ How long?_________
 Weight gain                                How much? ______ How long?_________
Metabolic
 Thyroid problems
 Diabetes
 Steroid/prednisone use                     When was the last time used?____________
Respiratory
 Cough                                         Dry   Mucous-      Green      Yellow      Bloody __________
 Shortness of breath                        Can you walk 2 blocks or climb 2 flights of stairs before
                                            becoming short of breath     No Yes
Heart
 Angina – chest pain with activity             Daily    Weekly         Monthly      Rarely
 High cholesterol/lipids
 Heart attack                               When? __________
 Heart failure
 Pulmonary edema – water in the lungs
 Ankle swelling
 Hand swelling
 Heart murmur
 Palpitations – extra heart beats
 High blood pressure
 Blood clots                                   Legs     Lung When?________
Neurologic
 Dizziness
 Vertigo – spinning sensation
 Fainting
 TIA – mini stroke
 Stroke or CVA
Gastrointestinal
 Loss of appetite
 Nausea
 Vomiting                                   Blood in the vomit:      No     Yes
 Heartburn
 Difficulty swallowing
 Hiatal hernia
 Ulcer                                      Bleeding from ulcer :      No     Yes
 Abdominal pain                             Upper         Lower             Right side       Left side
 Diarrhea
 Constipation
 Irritable bowel syndrome
 Crohn’s
 Rectal bleeding
 Change in bowel habits
 Liver disease
 Cirrhosis
 Hepatitis                                     Hepatitis A        Hepatitis B     Hepatitis C
                                                                                                            5
                                                                     Patient Name: ____________________
                                                                              DOB: ____________________

Urinary                                 Yes
 Straining to urinate
 Getting up at night to urinate               How many times?    1       2    3    4    ________
 Stream that is slow to start
 Leakage of urine
 Burning with urination
 Blood in urine
 Previous bladder or kidney infection
 Kidney stones
 Kidney failure
 Enlarged prostate
 Prostate cancer
Gynecologic
 Vaginal discharge
 Heavy periods
 Unexpected periods
 Pain with intercourse
 Endometriosis
 Menses                                       Age when menses started:____ Date Last Menses:________
 Pregnancies                                  Age when you delivered first baby:____
                                              No. of previous pregnancies:___ No. of deliveries:___
 Are you pregnant now?
 Menopausal Symptoms
 Menopausal
Breast
 Breast lump
 Breast pain
 Nipple discharge
Skin
 Jaundice – yellowing of skin or eyes
 Psoriasis
 Skin cancer                                    Basal cell   Squamous        Melanoma
 Hives
 Change in skin color
 Change in moles or scars
Hematologic
 Anemia
 Easy bruising
 Bleeding tendency
 Hemophilia
 Von Willenbrand’s
 Previous blood transfusions
Infectious Diseases
 HIV
 AIDS
 VRE
 MRSA
 Tuberculosis
Mental Health Issues
 Stress
 Anxiety
 Depression
 Treatment for mental illness                 Type of illness:_________________________________
 Chemical dependency                          Treatment:____________________________________


                                                                                                          6
                                                                    Patient Name: ____________________
                                                                             DOB: ____________________



                                             Surgical History

Head and Neck Surgery                  Yes     Please indicate year surgery was performed
 Tonsillectomy
 Nasal surgery
 Sinus surgery
 Surgery for sleep apnea
 Thyroid surgery
Breast Surgery
 Breast biopsy                                    Right   Left
 Breast lumpectomy                                Right   Left
 Mastectomy                                       Right   Left   Bilateral
 Breast augmentation
 Breast reconstruction                            Right   Left   Bilateral
Abdominal/Colon Surgery
  Appendectomy
 Gallbladder
 Hiatal hernia/reflux surgery
 Gastric bypass
 Stomach surgery for an ulcer
 Surgery for adhesions
 Partial colon removal                            Tumor     Diverticulitis
 Hemorrhoid surgery
 Colonoscope
 Groin hernia                                     Right   Left
 Umbilical hernia                                 Right   Left
 Incisional hernia                                Right   Left
Cardiovascular Procedures/Surgery
 Stress test – treadmill or chemical
 Heart catherization
 Cardiac angioplasty
 Cardiac stents
 Cardiac bypass surgery
 Cardiac valve replacement
 Pacemaker
 Implantable defibrillator
 Aortic aneurysm repair
 Carotid repair                                   Right   Left
 Vascular bypass                                  Right   Left    Abdominal
Gynecology/Urology
 Hysterectomy
 Caesarean section
 Tubal ligation
 Ovary removal
 Bladder suspension
 Laparoscopy
 Cystoscopy (bladder scope)
 Prostate surgery
 Kidney stone crushing - lithotripsy
 Kidney removal




                                                                                                         7
                                                                            Patient Name: ____________________
                                                                                     DOB: ____________________



                           Other Illnesses, Hospitalizations, or Operations
                                          (Not listed above)

 Year         Place                       Illness, Injury, Operation                     Doctor




 Have you or a family member had a reaction to anesthesia?             No       Yes
 _______________________________________________________________________
 Do you have any surgical implants or metal inside your body? No Yes
 Location:_____________________________________________________________________________


Pain Evaluation

To help us understand your pain, please circle the number that indicates how severe your pain is. A score
of 0 indicates no pain and a score of 10 indicates that this is the worst pain you have ever had.


                  [________________________________________]
 No Pain          0   1   2   3   4   5   6   7   8 9     10 Worst Pain Ever




Do you have an Advanced Directive or Living Will?                       No        Yes

Do you need information on Advanced Directives or Living Wills?         No         Yes

Do you have a Health Care Representative?                               No        Yes

Do you need information about appointing Health Care
Representative?                                                         No        Yes




Date: _______________   Reviewed By: ___________________________________________________



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Description: Male Breast augmentation