All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Your Present Medical Problem (nature and duration):
Personal Health History
Date of Last Physical Exam
Date of Last Chest X-Ray
Date of Last Chest EKG
List any medical problems that other doctors have diagnosed or any serious injuries or accidents you have had in the past:
Type of Surgery (eg. gallbladder or appendix removed)
Have you ever had a blood transfusion?
Are you presently taking any of the following medications? If yes, please give name and dosage
Blood Thinning Medication:
Birth Control Pills:
**If you are on Coumadin – please discuss this with the Dr. prior to surgery**
Allergies to medications:
Name the Drug
Reaction You Had
Do you have a latex allergy?
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
# of cups/cans per day?
Do you drink alcohol or beer?
How many drinks per week?
Do you use tobacco?
# of years
Or year quit
Do you currently use recreational or street drugs?
If so, please list all drugs:
FAMILY HEALTH HISTORY
Please list any blood relative who has had any of the following (please give relationship and details)
Congenital Heart Disease:
Heart Attack/Heart Disease:
High Blood Pressure:
High Fevers with Surgery:
PLEASE INDICATE IF YOU CURRENTLY HAVE OR HAVE HAD ANY OF THE FOLLOWING:
(Please give date of occurrence)
Epilepsy or Convulsions
Chest Pains, Angina
Chest Palpitations or Fast or Irregular Heart Beat
Congenital Heart Disease
Bronchitis or Chronic Cough
Shortness of Breath
Other Lung Problems
Heavy Skin Scarring
High Blood Pressure
Low Blood Pressure
Low Blood Sugar
Back Pain or Injury
In the past 60 days have you donated blood at another center?
In the past 7 days have you donated plasma at another center?
If you answered yes to either, please provide the date you last participated as a blood or plasma donor:
Date of last menstruation:
Number of pregnancies
Number of live births
Are you pregnant or breastfeeding?
IF YOU THINK YOU MAY BE PREGNANT, PLEASE LET YOUR PHYSICIAN KNOW. THIS IS IMPORTANT BEFORE WE ORDER ANY X-RAYS OR PERFORM ANY SURGICAL PROCEDURES
Do you have or have you had:
Other breast surgery?
Diagnosis of breast cancer?
Painful or tender breasts?
Blood relatives with breast cancer?
By signing below, I certify that this health history questionnaire has been filled out honestly and is accurate to the best of my knowledge. I have notified staff if there is a question that I don't understand and it has been sufficiently clarified.