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San Francisco Surgical Medical Group
Name
*
First Name
Last Name
What name would you prefer to be called?
Date of Birth
*
What is the reason for your visit today?
*
Please detail any recent imaging you have had that is relevant to your medical condition. (Eg: CT Pelvis on 5/9/21 at Sutter Santa Rosa)
Who referred you to our practice?
Primary Care Physician (Enter full name, include address if not local)
*
Other physicians you would like your reports to be sent to (full name + address if not local)
*
Personal Medical History
Mark all that apply
Acid Reflux
Anemia
Arthritis
Asthma
Bleeding / Blood Disorder
Bronchitis
Crohn's Disease
Depression
Diabetes
Emphysema
Epilepsy / Seizures
Glaucoma
Heart Problems
Hepatitis
High Blood Pressure
High Cholesterol or lipids
HIV
AIDS
Irritable Bowel Syndrome (IBS)
Immune Disorder
Kidney Disease
Liver Disease
Pneumonia
Stomach Ulcer
Stroke
Thyroid Disease
Tuberculosis
Ulcerative Colitis
Other
Please list ALL of your prior operations / surgeries and approximate dates
*
Do you have a pacemaker, defibrillator, or port?
*
Pacemaker
Defibrillator
Port
None
Pacemaker or Defibrillator Manufacturer's Name
Pacemaker or Defibrillator Model Number
Have you ever had a problem with Anesthesia?
*
Yes
No
Medications
Pharmacy information
*
Please list the medications and supplements you take regularly, dosage amounts, and why? (If none, please write "None")
*
Allergies
Are you allergic to any of the following?
*
Yes
No
Latex Allergy
Iodine
Shellfish
Adhesives/tapes
Any drugs/medications
Please list any medications you are allergic to and specify the reaction:
Social History
Social History
Single
Married
Widowed
Divorced
Domestic Partner
Decline
Marital Status
Heterosexual
Homosexual
Bisexual
Decline
Sexual Orientation
*
Never
Rarely
Moderate
Drinks/day
Use of Alcohol
*
Never
Previously, but quit
Current packs/day
Quit Date
Comments
Use of Tobacco
Use of smokeless tobacco (snuff, chew, vaping)
*
Never
Type/Frequency
Decline
Use of drugs
*
Yes
No
Do you engage in anal-receptive intercourse?
Family History
Mark if your blood-related relatives have:
Relative(s) - Include paternal/maternal info
Comments (Please specify)
Colon Polyps
Crohn's /
Ulcerative Colitis
Thyroid / Endocrine Problems
Has anyone in your family had cancer?
*
No
Yes
Relationship to you (paternal/maternal side) and type of cancer
Review of Systems (ROS)
Constitutional Symptoms
*
Good General Health
Weight Gain
Weight Loss
Fever/Sweats
Fatigue
Headache
Skin
*
No Symptoms
Rashes
Psoriasis
Bruise Easily
Abnormal Lumps
Nose
*
No Symptoms
Sinus Problems
Breathing Problems
Cardiovascular
*
No Symptoms
Palpitations
Heart Murmur
Chest Pain
Irregular Heartbeat
Ears
*
No Symptoms
Decreased Hearing
Ringing in Ears
Genitourinary
*
No Symptoms
Blood in Urine
Frequency of Urination
Painful Urination
Loss of Bladder Control
Enlarged Prostate
Gastrointestinal
*
No Symptoms
Nausea/Vomiting
Constipation
Diarrhea
Blood in Stool
Loss of Bowel Control
Endocrine
*
No Symptoms
Excessive Thirst/Appetite
Neurologic
*
No Symptoms
Headache/Migraine
Dizziness
Eyes
*
No Symptoms
Visual Loss
Double Vision
Painful Eyes
Throat
*
No Symptoms
Sore Throat
Hoarseness
Snoring
Respiratory
*
No Symptoms
Shortness of Breath
Wheezing
Cough
Musculoskeletal
*
No Symptoms
Fractures/Sprains
Osteoporosis
Joint Swelling
Other (Please include any pregnancy and # of weeks):
*
Height
Weight (lbs)
Amount
Submit
Should be Empty: