Surgical Specialists

First, Middle, Last, Suffix

If you referred yourself, please type "SELF"

If you do not have a Primary Care Provider, please type "NONE"

Please note approximate duration of your complaint

Yes

No

NO KNOWN ALLERGY

Iodine

Seafood

Latex

Adhesives

Penicillins

Cephalosporins

Sulfa

Fluoroquinolones (Cipro, Levaquin, etc.)

Tetracycline/Doxycycline

Erythromycin

Codeine

Dilantin

NSAIDs (non-steroidal anti-inflammatory drugs)

ACE Inhibitors

Statins

Eggs

Peanuts

Other not listed (see below)

Adverse reactions to medications or other substances, leading to rash, hives, throat swelling, shortness of breath, etc. [NOT merely nausea or vomiting]. If your allergen is not listed, please inform the physician at the time of your visit.

Please enter in any medication allergy not listed above

Please list ALL prescription medications, including dose and frequency of use. Be sure to include all aspirin products or blood thinners. If you are not taking prescribed medications, please type "NONE".

Please list ALL non-prescription medications, vitamins and supplements, including doses and frequency of use. If you none, please type "NONE".

Yes, I am currently taking steroids

Yes, I have stopped taking steroids within the last month

No

Have you recently taken any steroids (prednisone, Decadron, etc.)?

Warfarin (Coumadin)

Eliquis

Pradaxa

Xarelto

Aspirin

Ibuprofen (Motrin)

Naproxen (Aleve)

Meloxicam (Mobic)

Celebrex

Plavix

Effient

Aggrenox

Fish Oil

Vitamin E

Brilinta

I DO NOT TAKE ANY OF THESE CLASSES OF DRUGS

Please check the appropriate box(es) regarding these medications

Single

Married

Divorced

Separated

Widowed

Other

Yes

No

If you have never used tobacco, skip the next 2 questions

Enter number of packs/day

Enter number of years passed since you last used tobacco

Yes

No

If you do not consume alcohol (including beer and wine), skip the next question

How many alcoholic beverages do you consume per day?

Yes

No

If you do not use recreational drugs, skip the next question

Heart Disease

Diabetes Mellitus

Hypertension

Stroke

Aneurysm

Crohn's Disease

Ulcerative Colitis

Colon Cancer

Stomach Cancer

Pancreatic Cancer

Lung Cancer

Prostate Cancer

Bladder Cancer

Breast Cancer

Ovarian Cancer

Uterine Cancer

Melanoma

Leukemia

Lymphoma

Thyroid Cancer

Parathyroid Tumor

Adrenal Tumor

Complications with General Anesthesia

NONE OF THE ABOVE

Please check the appropriate boxes for diseases of immediate family members (blood relatives)

Asthma

Emphysema/COPD

Sleep Apnea

Tuberculosis

Lung collapse/pneumothorax

Lung surgery

Tracheostomy

Pulmonary emboli (lung blood clots)

Vena cava filter

High blood pressure

Heart arrhythmia

Pacemaker

Defibrillator

Heart valve disease

Artificial heart valve

Coronary artery disease/heart attack

Heart stent

Congestive heart failure

High cholesterol

Carotid artery disease

Stroke/TIA

Aneurysm

Peripheral vascular disease/claudication

Impotence/erectile dysfunction

Leg stent

Kidney disease

Kidney stones

Dialysis patient

Diabetes Mellitus

Visual loss/blindness

Hearing loss/deafness

Seizures

Brain tumor

Shingles

Neuropathy

Alzheimer's dementia

Depression

Manic-Depression

Schizophrenia

Attention deficit disorder

Thyroid dysfunction

Parathyroid dysfunction

Pituitary dysfunction

Adrenal dysfunction

Pancreas dysfunction

Pancreatitis

Hepatitis

Liver disease

Hiatal hernia/acid reflux

Stomach ulcer

Gastritis

Gallbladder disease

Crohn's disease

Ulcerative Colitis

Diverticulitis

Colon polyps

Hemorrhoidal disease

Perirectal abscess

Anal fistula

Anal fissure

Lupus

Rheumatoid arthritis

Osteoarthritis

Joint replacement

Spinal disc disease

Skin cancer

Melanoma

Thyroid cancer

Breast cancer

Lung cancer

Esophageal cancer

Stomach cancer

Liver cancer

Pancreatic cancer

Colon cancer

Rectal cancer

Anal cancer

Bladder cancer

Prostate cancer

Testicular cancer

Ovarian cancer

Uterine cancer

Sarcoma

Leukemia

Lymphoma

Multiple myeloma

Cataract extraction

NONE OF THE ABOVE

Please list ALL chronic medical conditions, and all illnesses requiring hospital care (with approximate dates of treatment) NOT ALREADY ADDRESSED IN THE PREVIOUS SECTION. If you have no significant past medical history, please type "NONE"

Please list ALL operations, including approximate dates of treatment. If you have no significant past surgical history, please type "NONE"

Yes

No

For men please enter n/a

Yes, I am currently using HRT

Yes, I previously used HRT

No, I have never used HRT

Not applicable

Good general health

Fatigue

Weakness

Fever

Chills

Night sweats

Loss of appetite

Significant weight loss

Significant weight gain

Dizziness/lightheadedness

Insomnia

Recent change in vision

Eye disease or injury

Blind in either eye

None of the above

Recent change in hearing

Ringing in ears

Vertigo

Deaf in either ear

Hoarseness

Pain with swallowing

Difficulty swallowing

None of the above

Chest pain/angina at rest

Chest pain/angina with exertion

Palpitations

Shortness of breath with exertion

Shortness of breath when lying flat

Ankle swelling

Leg pain with walking

None of the above

Dry cough

Cough with foul sputum

Cough with blood

Wheezing

Shortness of breath

History of tuberculosis (TB)

None of the above

Nausea

Vomiting

Heartburn

Difficulty swallowing

Abdominal Pain

Diarrhea

Constipation

Change in stool caliber

Rectal bleeding

Black or tarry stools

Jaundice

Incontinence of stool

None of the above

Blood in urine

Pain on passing urine

Difficulty starting stream of urine

Frequent urination

Urinary incontinence

None of the above

Muscle pain

Joint pain

Low back pain (lumbago)

None of the above

Rash

Itching

Change in mole

Change in nails

New skin lesion

None of the above

Breast lump

Breast pain

Nipple drainage

Nipple bleeding

None of the above

Headaches

Seizures

Numbness

Pins and needles

Loss of coordination

Difficulty with speech

Difficulty with balance

None of the above

Memory loss

Confusion

Depression

Anxiety/Panic Attacks

None of the above

Unusual intolerance of heat or cold

Excessive thirst or urination

Goiter

None of the above

Anemia

Bleeding or bruising tendency

Sickle cell anemia or trait

History of blood transfusion

Blood clots in legs or lungs

Enlarged glands/lymph nodes

None of the above

HIV positive

AIDS

Organ transplant

None of the above

Abnormal vaginal discharge

Abnormal vaginal bleeding

None of the above

Penile discharge

Testicular pain

Testicular swelling or mass

None of the above

I have received a pneumococcal vaccine (e.g. Pneumovax)

I have NEVER received a pneumococcal vaccine

All immunocompetent individuals aged 65 and older should receive a pneumococcal vaccine

I have never had a colonoscopy

I have had a colonoscopy within the last 10 years

My last colonoscopy was more than 10 years ago

I have never had a mammogram

I have had a mammogram within the last year

My last mammogram was more than 1 year ago

Yes, I have a Living Will

No, I do not have a Living Will

If you have a Living Will, please bring a copy to your office visit. To learn more, visit: http://aging.sc.gov/legal/Pages/LivingWillAndPowerOfAttorney.aspx

Yes, I have a Health Care Power of Attorney

No, I do not have a Health Care Power of Attorney

If you have a Health Care Power of Attorney, please bring a copy to your office visit. To learn more, visit: htttp://aging.sc.gov/legal/Pages/LivingWillAndPowerOfAttorney.aspx

Yes

No

My religious beliefs prohibit me from accepting blood or blood product transfusions, even in the event of a life-threatening emergency

Patient

Guardian

Available Forms

Patient Medical History

Social History

Family Medical History

Personal Medical History

Obstetrical/Gynecologic History

Review of Systems

Preventative Care

Advance Directives