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Patient Health History Questionnaire

* Required Fields
* First Name
* Last Name
* Birthdate	(format as mm/dd/yyyy)
* Surgery Date	(format as mm/dd/yyyy)
* Phone Number	(xxx-xxx-xxxx)

1. History of Neurologic Problems
* Stroke	YesNo Comments
* TIA or "Mini Stroke"	YesNo Comments
* Paralysis	YesNo Comments
* Seizures	YesNo Comments
* Alzheimers	YesNo Comments
* Dementia	YesNo Comments
* Memory Loss	YesNo Comments
* Guillian Barre Syndrome	YesNo Comments
* Brain Tumor	YesNo Comments
* Parkinson's Disease	YesNo Comments
* Head Trauma	YesNo Comments

2. HEENT Problems
* Glaucoma	YesNo Comments
* Cataracts	YesNo Comments
* Macular Degeneration	YesNo Comments
* Blindness	YesNo Comments
* Deafness	YesNo Comments
* Throat Problems	YesNo Comments
* Difficulty Swallowing	YesNo Comments
* Eye Glasses	YesNo Comments
* Dentures	YesNo Comments
* Partials	YesNo Comments

3. History of Heart Problems
* Heart attack	YesNo Comments
* Chest pain	YesNo Comments
* Rheumatic Fever	YesNo Comments
* High blood pressure	YesNo Comments
* Congestive heart failure	YesNo Comments
* Blood clots	YesNo Comments
* Enlarged Heart	YesNo Comments
* Born with Heart Problems	YesNo Comments
* Irregular heart beat	YesNo Comments
* Murmur	YesNo Comments
* Pacemaker	YesNo Comments
* Implanted defibrillator	YesNo Comments
* Heart Surgery	YesNo Comments
* Stent	YesNo Comments
* Valve Replacement	YesNo Comments

4. History of Lung Problems
* Pneumonia or Bronchitis	YesNo Comments
* Shortness of breath	YesNo Comments
* Asthma	YesNo Comments
* Reactive Airway	YesNo Comments
* COPD	YesNo Comments
* Emphysema	YesNo Comments
* Tuberculosis	YesNo Comments
* Tracheostomy	YesNo Comments
* Cystic Fibrosis	YesNo Comments
* Blood clot in the lung	YesNo Comments
* Recent Lung Infection	YesNo Comments

5. History of Stomach or Intestinal Problems
* Reflux or GERD	YesNo Comments
* Hiatal hernia	YesNo Comments
* Ulcers	YesNo Comments
* Hepatitis	YesNo Comments
* Liver Disease	YesNo Comments
* Bloody Stools	YesNo Comments
* Irritable Bowel	YesNo Comments
* Bowel Obstruction	YesNo Comments
* Colostomy/Ileostomy	YesNo Comments

6. History of Kidney or Urinary Problems
* Urinary tract infections	YesNo Comments
*Incontinence	YesNo Comments
*Prostate Problems	YesNo Comments
* Kidney stones	YesNo Comments
* Urinary Stents	YesNo Comments
* Renal Disease	YesNo Comments
* Dialysis	YesNo Comments

7. History of Endocrine Problems
* Pancreatitis	YesNo Comments
* Thyroid Disease	YesNo Comments
* Diabetes	YesNo Comments
If Diabetic, do you use insulin	YesNo Comments
If Diabetic, how long has it been since diagnosis?

8. History of Blood Problems
* Anemia	YesNo Comments
* Leukemia	YesNo Comments
* Previous Blood Transfusion	YesNo Comments
If Blood Transfusion, any Reaction	YesNo Comments
* Clotting Disorder	YesNo Comments
* Immune Deficiency	YesNo Comments

9. History of Muscle or Bone Problems
* Arthritis	YesNo Comments
* Osteoporosis	YesNo Comments
* Back Problems	YesNo Comments
* Fibromyalgia	YesNo Comments
* Cerebral Palsy	YesNo Comments
* Multiple Sclerosis	YesNo Comments
* Myasthenia Gravis	YesNo Comments

10. History of Skin Problems
* Pressure Ulcers	YesNo Comments
* Skin Diseases or Disorders	YesNo Comments

11. History of Psychological Problems
* Anxiety	YesNo Comments
* Depression	YesNo Comments
* Schizophrenia	YesNo Comments
* Bipolar Disorder	YesNo Comments
* Previous Suicide Attempt	YesNo Comments

12. History of Cancer Diagnosis
If Cancer, where
Radiation for treatment	YesNo Comments
Chemotherapy for treatment	YesNo Comments
How long has it been since diagnosis of cancer?

13. Surgery
Please list any surgeries you have had in your lifetime

14. Anesthesia
* Have you ever had a reaction to being put to sleep with anesthesia?	YesNo
If you have had a reaction to anesthesia, what happened?

15. History of Tobacco, Alcohol and Drug Use
* Tobacco	YesNo Comments
* Tobacco use within the last 12 months	YesNo Comments
If yes, please indicate how much tobacco you use
* Alcohol	YesNo Comments
If yes, please indicate how much alcohol you use
* Recreational Drugs	YesNo Comments
If yes, please indicate how often you use drugs

16. Resistant Organisims
* AIDS	YesNo Comments
* HIV	YesNo Comments
* Drug Resistant Organisms	YesNo Comments
* MRSA	YesNo Comments
* VRE	YesNo Comments
* VRSA	YesNo Comments

17. History of Pain
* Long Term Pain	YesNo Comments
* Poor Pain Control	YesNo Comments

18. Miscellaneous
* Implanted Devices	YesNo Comments
Other Medical History

19. Medications and Dose
Please list prescription & nonprescription

20. Allergies
Medications, foods, latex and/or dyes