MIDWEST HAND SURGERY PATIENT HEALTH HISTORY
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Reason for visit/injury
*
Allergies to Medications or Other
*
Name/Address of Preferred Pharmacy
Medications only refilled during normal business hours, M-F 8:30am-5pm
Are you pregnant?
*
Please Select
Yes
No
Not Sure
N/A
Current Medications & Strength (write 'none' if there are no current medications)
*
Surgical History
Smoking History
*
Yes
No
If yes, how much?
Alcohol Use
*
Yes
No
If yes, how much?
Recreational Drugs
*
Yes
No
If yes, how much?
Year of last tetanus shot
MEDICAL HISTORY
Do you have a history of:
Type a question
*
Yes
No
Asthma/Bronchitis/Shortness of Breath
Abdominal Pain/Ulcer
Anemia/Bleeding Disorders
Thyroid Problem
Cancer
Stroke/Neurological Problems
AIDS/AIDS Related Illness
Anesthesia Complications
Heart Disease/Chest Pain
High Blood Pressure
Diabetes
Arthritis
Mental Problems/Chronic Fatigue
Anesthesia Complications
Any Familial Disease?
Bleeding Disorders
Today's Date
*
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: