<p> REGIONAL INSTITUTE OF HEAD, NECK & RECONSTRUCTIVE SURGERY</p><p>PATIENT PERSONAL HISTORY</p><p>Name: ______Date: ______</p><p>Age: ______DOB: ______</p><p>In order that we may know a little about your background history, please answer the following questions about your present problem and medical history.</p><p>1. Please briefly describe the medical problem(s) that brought you here.</p><p>2. When did your symptoms first appear?</p><p>3. Have you seen any other doctors for this problem? If so, when?</p><p>GENERAL MEDICAL HISTORY</p><p>4. Have you ever been hospitalized? Please list reason and approximate date.</p><p>5. Have you ever had surgery? Please list each one with date.</p><p>6. Have you ever had any problems with anesthesia?</p><p>7. Do you have any allergies to medications? Please list them below.</p><p>Do you have an allergy or sensitivity to latex, lidocaine, novacaine, adhesive tape? Any other topical products?</p><p>8. Please list your current medications.</p><p>9. Are you a diabetic? If yes, insulin, pill or diet control. How many years?</p><p>10. Are you under treatment for high blood pressure? For how long?</p><p>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?</p><p> 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?</p><p>13. Is there any possibility that you are pregnant? (Females only)</p><p>14. Please check which of the following medical problems apply to you: </p><p>_____ 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</p><p>HAVE YOU EVER HAD ANY PROBLEMS OR DISEASES IN THE AREAS LISTED BELOW? IF YES, PLEASE EXPLAIN.</p><p>NO YES IF YES EXPLAIN Head</p><p>Eyes</p><p>Ears</p><p>Mouth ;</p><p>Throat</p><p>Lungs</p><p>Heart</p><p>Stomach</p><p>Bowels</p><p>Kidneys</p><p>Bladder</p><p>Liver ,</p><p>Nervous System</p><p>Extremities</p><p>Circulation</p><p>Other Areas</p><p>15. Have you or any family members had problems with general anesthesia in the past?</p><p>16. Family history for diseases, problems, cancer, etc.? HOW DID YOU LEARN ABOUT US?</p><p>Please make the appropriate statement that applies to you:</p><p>My friend, ______, told me about Dr. Peter Schmid.</p><p>My doctor, Dr. ______, referred me.</p><p>Your location is convenient to my home or office.</p><p>I noticed your name in the yellow pages.</p><p>I noticed your service in the newspaper (______).</p><p>The hospital referral service recommended Dr. Peter Schmid.</p><p>I attended your patient seminar on ______at ______</p><p>Other ______</p><p>______</p><p>______Patient Signature Date PMS/rdc 12/9/09</p>