Linda Huang, MD: Medical History Form

Medical History Form

Please complete this form in full before your preoperative appointment. This helps our team understand your complete health history so we can plan for a safe, smooth surgery!

The form covers your allergies, current medications, medical history by body system, surgical history, and social history. You'll need to have your medication list handy while completing this form — you'll need names, dosages, and how often you take each one.

Patients typically complete this form in roughly 10 minutes. So give yourself some time!

Full Name*

First NameLast Name
Email*
example@example.com
Date of Birth:*

MonthDayYear
Date
Height:*
Weight:*
Sex:

MaleFemaleOther
Name of the person who will care for you after surgery:*
Phone number of the person who will care for you after surgery:*
Please enter a valid phone number.Format: (000) 000-0000.
Phone number where you will be after surgery:*
Format: (000) 000-0000.
REMINDER: NO FOOD OR DRINK AFTER MIDNIGHT THE NIGHT BEFORE YOUR SURGERY

Please list and describe any allergies you may have below. *

Rows	YES	NO
Do you have any food allergies?
Drug allergies?
Latex/rubber allergies?

If yes to any of the allergy questions above, please provide comments / explain here:
NOTE: latex allergies require special equipment and added expense. We can order a blood test to confirm an allergy to meds or latex if needed.

Please list any medications you are taking (aspirin, herbal, prescribed, over-the-counter, steroids, diet pills, other)

If you are taking a diuretic, such as Lasix or HCTZ, we need a serum potassium level. This is a blood test that your regular doctor may have. We can order it from Quest Labs on the fourth floor if you do not have a recent one.

All diet pills and GLP-1s should be stopped at least two weeks before surgery (e.g., phentermine/Fastin or anything with ephedra or ma huang).

Did your Primary Care Provider (PCP) instruct you to stop taking any of your medications in preparation for surgery?

Do you smoke?*
If so, for how long have you been smoking and how much per day?
Remember, smoking increases the risk of poor wound healing. Please try to stop smoking for as long as possible both before and after surgery.

Healthy patients under the age of sixty do NOT require routine tests before general anesthesia. However, if you would like to have any tests done in preparation for surgery, please let us know. All tests can be ordered. However, we recommend they be done at least ONE week before surgery, if possible.
Would you like to have an EKG?*

YesNo
A chest x-ray? (Recommended if you smoke)*

YesNo
Blood tests? A serum potassium, required if you are on a diuretic, or any blood thinners, or insulin.*

YesNo

Married or single? Significant other?*
Children? Number and ages?
Occupation?
After surgery, who will stay with you?*
In case of an emergency, are there any other family members or friends we may try to contact? Please include their name and phone numbers here.

Do you drink alcohol?*

YesNo
Do you use recreational drugs?*

YesNo
Do you have any body piercings?*

YesNo
Do you have any contagious diseases? (HIV, Herpes...)*

YesNo
If you answered “Yes” to any of the above, please provide additional details (e.g., average number of alcoholic drinks per week; type and frequency of recreational drug use; etc.):

Please list all prior surgeries you've had.

Were you able to list ALL of you surgeries above?

YESNO
If not please email the full list to reception@lindahuangmd.com or bring the list to your preoperative appointment!
Do you have any implants or prosthesis?

YESNO

Have you or anyone in your family had an unusual reaction to anesthesia such as high temp, difficulty waking up, nausea and/or vomiting?

YESNO
If "YES" to you or anyone in your family had an unusual reaction to anesthesia such as high temp, difficulty waking up, nausea and/or vomiting, please describe below.
Any family history of cancers?
Any family history of any medical problems?
When was your last menstrual period:

MonthDayYear
Date
Are you pregnant or trying to get pregnant?

YESNO
Patient (Responsible adult) signature:
Should be Empty:

Rows	YES	NO	Comments / Explanation
Do you have or have you ever had angina/chest pain?
High blood pressure?
Low blood pressure?
Rheumatic fever?
Congestive heart failure?
Mitral value prolapse?
Heart surgery / stent / catheter? (add date inserted and type in comments as needed)
Heart attack? (add dates in comments as needed)
Palpitations or an irregular heart beat?
Do you have a pacemaker / defibrillator?

Rows	YES	NO	Comments/Explanation
Do you have asthma?
Restrictive airway disease (RAD)?
Bronchitis / COPD
Sleep apnea?
Do you have or have you ever been exposed to TB?
Do you use a nebulizer or Home Breathing Machine?
Do you ever have shortness of breath?
Do you smoke / use tobacco? (if yes, please include how much in comments)
Are you using oxygen at home?
Have you had a cold in the past two week?
Do you have any other pulmonary conditions?

Rows	YES	NO	Comments/Explanation
Are you a diabetic?
Do you have hypoglycemia?
Is your diabetes diet controlled?

Rows	YES	NO	Comments/Explanation
Burning when urinating?
Bleeding when urinating? (if yes, please include frequency in comments)
Have you ever been on dialysis? (if yes, please include frequency in comments)
Do you have any urinary problems?

Rows	YES	NO	Comments/Explanation
Have you ever had a stroke or TIA? (if yes, add dates in comments as needed)
Have you ever had any seizures?
Do you suffer from any paralysis? (if yes, please add details in comments)
Do you have multiple sclerosis?
Lupus or scleroderma?
Other neurological conditions? (if yes, please add details in comments)

Rows	YES	NO	Comments/Explanation
Do you have ulcers or hiatal hernia?
Acid reflux disease?
Gallbladder conditions?
GI/rectal bleeding?

Rows	YES	NO
Have you ever had a blood transfusion? (if yes, please include dates below)
Blood Clots?
Has any family member had blood clots?
Anemia?
Other blood conditions? (explain below)

Rows	YES	NO
Do you have joint problems?
Multiple sclerosis?
Arthritis?
Other musculoskeletal conditions (explain below)?

Rows	YES	NO
Rashes?
Bruises?
Does your skin tear easily?
Other skin conditions? (explain below)

Rows	YES	NO
Anxiety or panic disorder?
Substance abuse?
Developmental delays?
Other psychiatric conditions? (explain below)

Rows	YES	NO
Vision impairments? Including glasses/contacts?
Other impairments/disabilities? (explain below)