PARC Surgical Center - Patient Medical History

1

Patient Name* This field is required.

First Name

Last Name

2

Patient Birth Date* This field is required.

3

Is the patient a Minor?(17 years of age or younger)

YESNO

4

Primary Care Physician

5

Referring Physician (if different than PCP)

7

Ethnicity/Race (select all that apply):

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

Caucasian

8

Primary Language Spoken

9

Is an interpreter needed?

YESNO

10

Chief Complaint

Reason for Scheduled Visit

11

Does the patient have to strain when urinating?* This field is required.

Yes

No

12

Does the urine spray or go to a side?* This field is required.

Yes

No

13

Does the patient stand to urinate?* This field is required.

Yes

No

14

Has the patient had urine infections?* This field is required.

Yes

No

15

If yes, with fever?

Yes

No

16

Does the patient have pain when urinating?* This field is required.

Yes

No

17

Is the penis bent when the patient has an erection?

Yes

No

18

Are immunizations UP TO DATE?* This field is required.

Yes

No

19

Is the patient allergic to any medications?* This field is required.

Yes

No

20

If yes, please list allergies and reactions:

21

Is the patient allergic to LATEX?* This field is required.

Yes

No

22

Is the patient taking prescribed medications?* This field is required.

Yes

No

23

If yes, please list along with dosages and frequency.

24

Is the patient taking any non-prescribed medications? (i.e. herbals, alternative medications) How many times per day? Please list along with dosages and frequency.

25

Has the patient ever been hospitalized (surgical OR non-surgical)?* This field is required.

Yes

No

26

If yes, please list reason/when:

27

Has the patient had any operations?* This field is required.

Yes

No

28

If yes, please list what/when:

29

Do any family members have: (please select all that apply)* This field is required.

Hypospadias

Anesthesia Problems

Bleeding Problems

Unusual Scarring or Keloids

None of the Above or Unknown

30

If yes, please list which family member and problem:

31

General Health* This field is required.

Losing Weight on Growth Curve

Recent Fevers

Recent RSV Infection

None of the Above

32

HEENT* This field is required.

Vision Problems

Difficulty Hearing

Loose Teeth

None of the Above

33

Heart* This field is required.

Heart Birth Defect

Irregular Heart Rate

None of the Above

34

Circulation* This field is required.

Bleeding Problems

None of the Above

35

Lungs* This field is required.

Asthma

Recent Pneumonia

History of Needing Oxygen

None of the Above

36

Stomach* This field is required.

Feeding Problems

Stomach Reflux

Constipation

None of the Above

37

Genitourinary* This field is required.

Hernia or Prior Hernia Surgeries

Undescended Testicle

Prior Testicle Surgery

Problems with Erections

None of the Above

38

Skin* This field is required.

Eczema

Problems with Wound Healing

Unusual Bruising

None of the Above

39

Endocrine* This field is required.

Diabetes

Thyroid

Adrenal Gland Problems

None of the Above

40

Allergic/Immunity* This field is required.

Seasonal Allergies

Food Allergies

MRSA Infection

None of the Above

41

Neurologic* This field is required.

Seizures

Dizziness

Weakness

None of the Above

42

If other, please list:

43

Does the patient have any anesthesia complications?* This field is required.

YESNO

44

If yes, please explain.

45

Does the patient have a family history of anesthesia complications?* This field is required.

YESNO

46

If yes, please explain.

47

Was the patient full-term at birth?* This field is required.

YESNO

48

If no, were there any complications?

51

Does the patient have any HEART/VALVE problems?* This field is required.

YESNO

52

If yes, please select what type.

Murmur

Arrhythmia

Defect

Other

53

Does the patient have any BREATHING/LUNG problems?* This field is required.

YESNO

55

Does the patient have diabetes?* This field is required.

YESNO

56

If yes, what type?

Type 1

Type 2

Other

57

Is the patient around SECONDHAND SMOKE?* This field is required.

YESNO

58

Are the patient's IMMUNIZATIONS up to date?* This field is required.

YESNO

59

If no, please explain.

60

Is the patient currently experiencing or do they have a past history of abuse or neglect?* This field is required.

YESNO

61

Does the patient have any food or drug allergies?* This field is required.

YESNO

62

If yes, please list with reaction:

63

Is the patient's growth and development normal per their age?* This field is required.

YESNO

64

If no, please explain the delay:

65

Does the patient have loose teeth?* This field is required.

YESNO

66

If so, where?

67

Does the patient have BLEEDING DISORDERS/ANEMIA?* This field is required.

YESNO

68

If yes, please select type:

Anemia

Von Willebrand

Blood Clots

Other

69

Has the patient had a RECENT cold, flu or infection?* This field is required.

YESNO

70

Has the patient had a flu shot?* This field is required.

YESNO

71

Has the patient had recent exposure to contagious diseases?* This field is required.

YESNO

72

If yes, please explain:

73

Has the patient traveled outside of the country in the past month?* This field is required.

YESNO

74

If yes, where?

75

Does the patient have any cultural or religious beliefs that will affect the care we provide?* This field is required.

YESNO

76

Please list any past surgeries and/or procedures:

77

Please list any non-surgical hospital stays:

78

Do you have any anesthesia complications?

YESNO

79

If yes, please explain:

80

Do you have a family history of anesthesia complications?

YESNO

81

If yes, please explain:

82

Do you have any difficulty with MOBILITY?

YESNO

83

If yes, do you use:

Wheelchair

Cane

Walker

Other

84

Do you have any difficulty with your VISION?

YESNO

85

If yes, do you use:

Glasses

Contacts

86

Do you have any difficulty with HEARING or COMMUNICATION?

YESNO

87

If yes, do you use hearing aids?

YESNO

88

Do you have any difficulty with speaking?

YESNO

89

Do you have any difficulty with swallowing?

YESNO

90

Do you have any heart or valve problems?(HTN, Afib, Heart Attack, Murmur, Arrhythmia)

YESNO

91

Do you have any breathing or lung problems?(Asthma, Bronchitis, COPD, Sleep Apnea, Emphysema, OSA)

YESNO

92

Do you have diabetes?

YESNO

93

If yes, which type of diabetes?

94

Do you have thyroid problems?

YESNO

95

If yes, which type?

Hypothyroidism

Hyperthyroidism

96

Do you have neurological problems?(Seizures, Migraines, Stroke, TIA)

YESNO

97

Do you have implants?

YESNO

98

If yes, where?

99

Do you have skin problems?

YESNO

100

Could you be pregnant?

Yes

No

Not applicable

Type option 4

101

Last Menstrual Period:

Date

102

Do you consume alcohol?

YESNO

103

If yes, please indicate frequency:

104

Do you use tobacco OR are you around second hand smoke?

YESNO

105

If yes, please indicate what type and frequency:

106

Do you use recreational drugs?

YESNO

107

Do you have any food or drug allergies?

YESNO

108

If yes, please list with reaction:

109

Do you have bleeding disorders or anemia?(Anemia, Blood Clots, Von Willebrand)

YESNO

110

Have you had a RECENT cold, flu or infection?

YESNO

111

Do you have gastrointestinal problems?(GERD, Liver Disease, Hepatitis, HIV)

YESNO

112

Do you have muscle problems?

YESNO

113

Do you have difficulty opening your jaw or TMJ disorder?

YESNO

114

Do you have kidney problems or urinary tract infections?

YESNO

115

Do you have depression, anxiety, ADD, ADHD or autism?

YESNO

116

Have you had the flu shot?

YESNO

117

Have you had a pneumonia vaccine?

YESNO

118

Have you had recent exposure to contagious diseases?

YESNO

119

If yes, please explain:

120

Have you been outside of the country in the past month?

YESNO

121

If yes, where?

122

Signature of Patient (or Patient Representative)* This field is required.Please use your finger or mouse to create your e-signature.

Clear

123

Today's Date

Date

Hour

Minutes