Regional Institute of Head, Neck & Reconstructive Surgery

REGIONAL INSTITUTE OF HEAD, NECK & RECONSTRUCTIVE SURGERY

PATIENT PERSONAL HISTORY

Name: ______Date: ______

Age: ______DOB: ______

In order that we may know a little about your background history, please answer the following questions about your present problem and medical history.

1. Please briefly describe the medical problem(s) that brought you here.

2. When did your symptoms first appear?

3. Have you seen any other doctors for this problem? If so, when?

GENERAL MEDICAL HISTORY

4. Have you ever been hospitalized? Please list reason and approximate date.

5. Have you ever had surgery? Please list each one with date.

6. Have you ever had any problems with anesthesia?

7. Do you have any allergies to medications? Please list them below.

Do you have an allergy or sensitivity to latex, lidocaine, novacaine, adhesive tape? Any other topical products?

8. Please list your current medications.

9. Are you a diabetic? If yes, insulin, pill or diet control. How many years?

10. Are you under treatment for high blood pressure? For how long?

11. Do you use tobacco of any type? If not in use at present have you ever used tobacco?  Cigarettes  Chewing tobacco  Cigars  Pipe  Snuff How much do you/did you use per day? If you have quit, when did you quit? How long did you use tobacco?

 Less than one (1) year  1-5 years  5-10 years  10-20 years  Over 20 years 12. Do you drink alcohol? If so, how much per week?

13. Is there any possibility that you are pregnant? (Females only)

14. Please check which of the following medical problems apply to you:

_____ Diabetes _____ Eye problems _____ Emphysema _____ Thyroid disease _____ Glaucoma _____ Blood dvscrasias _____ High blood pressure _____ Dry Eyes _____ Anemia _____ Heart attack _____ Eye glasses/contacts _____ Hepatitis _____ Chest pain _____ Previous facial paralysis _____ Tuberculosis _____ Heart murmur _____ Epilepsy _____ Blood infections _____ Rheumatic fever _____ Asthma _____ Nervous' breakdown _____ Positive HIV _____ Psychiatric care

HAVE YOU EVER HAD ANY PROBLEMS OR DISEASES IN THE AREAS LISTED BELOW? IF YES, PLEASE EXPLAIN.

NO YES IF YES EXPLAIN Head

Mouth ;

Throat

Stomach

Bowels

Kidneys

Bladder

Liver ,

Nervous System

Extremities

Circulation

Other Areas

15. Have you or any family members had problems with general anesthesia in the past?

16. Family history for diseases, problems, cancer, etc.? HOW DID YOU LEARN ABOUT US?

Please make the appropriate statement that applies to you:

My friend, ______, told me about Dr. Peter Schmid.

My doctor, Dr. ______, referred me.

Your location is convenient to my home or office.

I noticed your name in the yellow pages.

I noticed your service in the newspaper (______).

The hospital referral service recommended Dr. Peter Schmid.

I attended your patient seminar on ______at ______

Other ______

______

______Patient Signature Date PMS/rdc 12/9/09