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English (US)
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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?
*
Who referred you to our practice?
Primary Care Physician (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
Anemia
Arthritis
Asthma
Bleeding / Blood Disorder
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 / Bronchitis
Stomach Ulcer / Acid Reflux
Stroke
Thyroid Disease
Tuberculosis
Ulcerative Colitis
Please list all of your prior operations 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
Please list the medications you take regularly and why? (If none, please write "None")
*
Allergies
Are you allergic to any of the following?
*
Yes
No
Latex Allergy
Iodine or shellfish
Adhesives/tapes
Any drugs/medications
Please list any medications you are allergic to:
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
Use of Tobacco
Never
Type/Frequency
Decline
Use of drugs
Yes
No
Do you engage in anal-receptive intercourse?
Family History
Mark if your relatives have:
Mother
Father
Sibling
Paternal Aunt/Uncle/Grandparent
Maternal Aunt/Uncle/Grandparent
Colon Polyps
Crohn's or ulcerative colitis
Thyroid or Endocrine Problems
Has anyone in your family had cancer?
*
No
Yes
Relationship to you and type of cancer
Review of Systems (ROS)
Constitutional Symptoms
*
Good General Health
Recent Weight Change
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
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