Plymouth Family Physicians - Preoperative History and Physical Questionnaire

Plymouth Family Physicians

Preoperative History and Physical Questionnaire

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

Doctor being seen

Dr. Mary Arenberg
Dr. George Schroeder

Name (required)

E-mail Address

Place of Surgery

Date of Surgery

Surgeon

Reason for surgery/type of surgery (if this is an orthopedic surgery please state if this is left or right sided)

PAST MEDICAL HISTORY: (please list year)

Any unusual childhood illnesses:

Past hospitalizations and surgeries:

Medical problems:

If you are female, what was the date of your last menstrual period?

CURRENT MEDICATIONS: (please list both prescription and non-prescription)

MEDICATION ALLERGIES:

Any history of Latex sensitivity or allergy: Yes No

SOCIAL HISTORY:

Marital Status

Do you have children? Yes No
If yes, what are their names and ages?

Occupation

Last year of school completed:

Tobacco use? Yes No
If yes, how many packs per day?

Number of years of smoking?

Chewing tobacco use? Yes No

How many days per week do you drink alcohol on an average?

How many alcohol drinks per week will you usually have?

Any other drug use? Yes No If yes, please explain.

Concerns about sexuality or sexual function?

FAMILY HISTORY:

Please list any illness in your family members such as heart disease, heart attacks, heart surgery, stroke, diabetes, cancer, high blood pressure, high cholesterol levels, lung disease, liver or kidney disease, depression or suicide.

Father

Health problems:

Mother

Health problems:

Brothers

Health problems:

Sisters

Health problems:

Paternal grandfather

Health problems:

Paternal grandmother

Health problems:

Maternal grandfather

Health problems:

Maternal grandmother

Health problems:

Any personal or family history of adverse reactions to anesthesia?
Yes No If yes, please explain.

Any personal or family history of bleeding disorders?
Yes No

If yes, please explain.

PROBLEMS WITHIN THE LAST YEAR:

Please check any problems listed below that you have had in the last year:

Fever, chills, night sweats

Headaches, head injuries, concussion

Eye problems (wear contacts or glasses?)

Loose or capped teeth

Cold or allergy symptoms

Ear problems, hearing loss, ringing, pain

Thyroid problems or x-ray treatment to neck or chest

Breast masses, breast discharge, breast pain

Breathing problems, shortness of breath, asthma, bronchitis, pneumonia, emphysema

High blood pressure, rheumatic fever, chest pain, palpitations or skipped beats, heart murmur

Heartburn, ulcers, gallstones, constipation, diarrhea, bloody or black bowel movements, abdominal pain

Kidney or bladder infection, leaking urine, pain with urination, kidney stones

Muscle pain, joint pain or swelling, broken bones, dislocations, muscle weakness

Seizure, loss of coordination, tremors, speech problems, memory loss, numbness, tingling

Skin changes, mole change, skin infections, hair loss, psoriasis

Bleeding from any site, clotting problems, bruising easily, transfusion
If yes to transfusions, what year?

Depression, poor sleeping, appetite problems, panic attacks, suicidal thoughts or attempts

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.