1220 New Scotland Rd. Suite 204

Capital Region Special Surgery

1220 New Scotland Rd. Suite 204

Slingerlands, NY 12159

518-439-4326-Phone

518-439-6143-Fax

Please take your time to fill out the following information as accurately as possible. This information will be helpful in making your office visit more efficient and thorough.

Name ______Date ______

Past Medical History

Check the box for any of the following conditions/diseases that YOU have now or in the past.

(DO NOT PUT YOUR FAMILY HISTORY HERE(Family is on next page), ONLY YOUR MEDICAL HISTORY)

Cancer History
☐ Cancer – Type ______
Endocrinology
☐ Diabetes – Type______
☐ Hyperthyroidism ☐ Hypothyroidism / Ears, Nose, Throat
☐ Glaucoma ☐ Vertigo
☐ Hearing Problems ☐ Nosebleeds
☐ Swallowing difficulty
Cardiovascular/Hematologic
☐ Anemia ☐ Heart Attack
☐ Coronary Artery Disease ☐ Stoke/TIA
☐ High Blood Pressure ☐ Heart Valve Disorders
☐ Peripheral Vascular Disease ☐ TIA
☐ Presence of stent/pacemaker/ defibrillator / Psychological
☐ Depression ☐ Anxiety
☐ Schizophrenia ☐ Bipolar Disorder
☐ ADD/ADHD ☐ PTSD
☐ Alcohol abuse ☐ Substance Abuse
Gastrointestinal
☐ GERD (Acid Reflux) ☐ Gastrointestinal Bleeding
☐ Crohns Disease ☐ Ulcerative Colitis
☐ Irritable bowel syndrome ☐ Stomach Ulcers / Musculoskeletal/Rheumatologic
☐ Bursitis ☐ Chronic Joint Pains
☐ Fibromyalgia ☐ Osteoarthritis
☐ Osteoporosis ☐ Osteopenia
☐ Rheumatoid Arthritis ☐ Carpal Tunnel Syndrome
Urological
☐ Chronic Kidney Disease ☐ Kidney Stones
☐ Urinary Incontinence ☐ Dialysis / Respiratory
☐ Asthma ☐ Bronchitis/Pneumonia
☐ Emphysema/COPD
Neurological
☐ Multiple Sclerosis ☐ Peripheral Neuropathy
☐ Seizures ☐ Balance Disorder
☐ Head Injury ☐ Headaches ☐ Migraines / Other
☐ ______
☐ ______
☐ ______
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Name ______

Surgical History

List any surgery you have ever had in the past:

Examples:

Tonsils and Adnoids; Appendix (appendectomy); Gallbladder (cholecystectomy) ; Heart (bypass surgery);

Carotid Artery (Endarterectomy); Leg arteries (vascular bypass surgery); Stomach surgery (gastric bypass or sleeve);

Uterus (hysterectomy); Prostate (prostatectomy); Eyes (cataract surgery, retina, or for glaucoma);

Neck (fusion); Back (laminectomy, fusion); Fracture (ORIF); Joints (knee, hip, or shoulder replacement)

1. / Date:
2. / Date:
3. / Date:
4. / Date:
5. / Date:
6. / Date:

☐ I have never had any surgeries.

Family History

Place a M for mother, F for father, S for sister, B for brother, and C for child in the box with the diagnosis.

High blood pressure / Stroke / Kidney disease / Blood clots / Neurologic disorder
Chronic pain / Migraine / Heart disease / Bleeding problems / Epilepsy
Emotional problems / Asthma / Diabetes / Thyroid disease
Substance abuse / Osteoporosis / Cancer (breast, colon, ovarian, thyroid, throat, kidney, pancreas)

Other diagnosis not listed above?

Social History

Tobacco use (smoke, chew, VAP,electronic):

☐ Currently use ☐ Formerly used ☐ Never used

☐ Packs per day? ______☐ Cans/Chews/VAP per day? ☐ How many years? ______☐ Quit Date: ______

Alcohol Use:

☐ Social Use – glasses/bottles per day______how often ______☐ Daily use of alcohol- glasses/bottles per day ______

☐ History of alcoholism ☐ Current alcoholism ☐Never drank alcohol

Illegal Drug Use:

☐ I do not use any illegal drugs ☐ I currently use illegal drugs

☐ I used illegal drugs in the past (not currently using): Date Quit______

Do you have a history of abusing prescription medications at any time? ☐ Yes ☐ No

Living Situation

☐ I live alone ☐ I live with ______

Occupation:______Page 2/4

Name ______

Review of Systems

Circle the following symptoms that you frequently have.

Constitutional symptoms / fever, weight loss, extreme fatigue / Skin / rash, changing mole
Eyes / double vision, sudden loss of vision / Neurological / headache, persistent weakness or numbness on one side of the body, falling
Ears, nose, mouth and throat / sore throat, runny nose, ear pain / Musculoskeletal / joint pain, muscle weakness
Cardiovascular / chest pain, palpitations / Psychiatric / depression, anxiety, suicidal thoughts
Respiratory / cough, wheezing, shortness of breath / Endocrine / excessive thirst, cold or heat intolerance, breast mass
Gastrointestinal / nausea, vomiting, abdominal pain, constipation, diarrhea, blood in stools / Hematologic: / unusual bruising or bleeding, enlarged lymph nodes
Genitourinary / impotence, irregular menses, vaginal bleeding after menopause, frequent or painful urination, bloody urine. / Allergic / hay fever
Non-Pain Medication

List any NON-PAIN MEDICATIONS below prescription or over-the-counter. Don’t forget to include blood thinners!

Put pain medications in the pain history form.

Medication Dose Frequency

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Name ______

Allergies

☐ I am not allergic to anything. ☐ I only have environmental (pollen, dust, etc) allergies.

Do you have any allergies to medications? ☐ Yes ☐ No If yes please list below.

Latex ☐ Yes ☐ No; IV contrast ☐ Yes ☐ No; Tape ☐ Yes ☐ No; Iodine ☐ Yes ☐ No; Foods ☐ Yes ☐ No

Medication/Food allergy Reaction

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