Patient Health Survey

Hand, Microsurgery and Reconstructive Orthopaedics, LLP

Patient Health Survey

Dear Patient,

We welcome the opportunity to participate in your medical care. We ask that you take a moment to answer some questions about your past medical history. This will help us determine the most appropriate treatment. We depend on you to provide accurate information on this health screening form. Thank you for your help and we look forward to caring for you.

General Information

Name __________________________ Age ______ Ht.____ Wt.______ Telephone____________
Personal Medical Doctor ______________________________________ Telephone____________
Personal Medical Doctor Address ____________________________________________________
Occupation __________________________________________ Last Date Worked ____________
Are you on disability? ________________ Modified Work? ________________

Health Survey Place "X" in proper column

Yes	No		Comments
O	O	1. Do you have any allergies?	___________________________
		Please List ______________________________________
		_______________________________________________
		2. List medications with dosage you take regularly.	___________________________
		Please List ______________________________________
		_______________________________________________
O	O	3. Do you take any medications occasionally?	___________________________
		Please List ______________________________________
		_______________________________________________
O	O	4. Do you smoke cigarettes?—Approx. how many each day?	___________________________
O	O	5. Are you an ex-smoker? When did you stop?	___________________________
O	O	6. Do you drink alcoholic beverages? How many ozs daily?	___________________________
O	O	7. Have you ever had any heart problems?	___________________________
O	O	Heart Bypass surgery? When?	___________________________
O	O	Angioplasty? When?	___________________________
O	O	High blood pressure?	___________________________
O	O	Low blood pressure?	___________________________
O	O	Rheumatic Fever? When?	___________________________
O	O	Heart Attack? When?	___________________________
O	O	Heart Murmur?	___________________________
O	O	Chest Pains?	___________________________
O	O	Irregular Heart Beat?	___________________________
O	O	Mitral Valve Prolapse?	___________________________
O	O	8. Have you ever had any lung problems?	___________________________
O	O	Hay Fever, Wheezing, Shortness of breath?	___________________________
O	O	COPD/Chronic bronchitis?	___________________________
O	O	Emphysema?	___________________________
O	O	Pneumonia? When?	___________________________

Place "X" in proper column Comments

Yes	No		Comments
O	O	9. Have you ever had any urinary problems?	___________________________
O	O	Urinary Infections?	___________________________
O	O	Difficulty voiding, enlarged prostate	___________________________
O	O	Other?	___________________________
O	O	10. Have you ever had any digestive tract problems?	___________________________
O	O	Ulcers? When?	___________________________
O	O	Jaundice/Hepatitis? When?	___________________________
O	O	Other?	___________________________
O	O	11. Have you ever had any musculoskeletal problems?	___________________________
O	O	Arthritis?	___________________________
O	O	Muscle weakness?	___________________________
O	O	Other?	___________________________
O	O	12. Have you ever had any neurological problems?	___________________________
O	O	Stroke? When?	___________________________
O	O	Convulsions/Epilepsy? Last episode?	___________________________
O	O	Fainting? Head Injury?	___________________________
O	O	Numbness/Tingling in extremities?	___________________________
O	O	13. Have you ever had any metabolic problems?	___________________________
O	O	Diabetes? If yes, do you take insulin or pills?
		Please specify.	___________________________
O	O	Thyroid disease? Other?	___________________________
O	O	14. Have you ever had hematologic problems?	___________________________
O	O	Bleeding tendency? (Do you bruise easily?)	___________________________
O	O	Sickle cell disease/trait?	___________________________
O	O	Anemia?	___________________________
O	O	15. Have you ever been treated for nervous or emotional problems?	___________________________
O	O	Depression?	___________________________
O	O	Other?	___________________________
O	O	16. Have you ever had surgery?	___________________________
		Type of anesthesia—
		O General (Put to sleep) O Local O Spinal	___________________________

Year

Operation

Type of anesthesia

Problems

_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Place "X" in proper column Comments

Yes	No
O	O	17. Has any member of your family had problems with anesthesia?	___________________________
O	O	18. Have you had any problems after using latex products (rubber gloves, blowing up balloons, etc.)?	___________________________

Female Patients Only

19. Could you be pregnant?

___________________________

If the Patient is a Child - Please Continue to Answer the Following Questions

O	O	20. Was your child premature?	___________________________
O	O	Was oxygen required?	___________________________
O	O	Any lasting effects?	___________________________
O	O	21. Did your child have yellow jaundice requiring transfusion?	___________________________
O	O	22. Does your child have any developmental delays?	___________________________
O	O	Any learning disabilities?	___________________________
O	O	23. Does your child have any problems that have not been mentioned?	___________________________

Patient or Parent/Guardian's Signature ___________________________________ Date _____________
Reviewed by _________________________________________________ R.N. Date ______________
Reviewed by _________________________________________________ M.D. Date ______________
Comments _______________________________________________________________________________
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