CAMC PHYSICIANS GROUP Mark Choueiri, MD, FACS GENERAL & VASCULAR SURGERY CENTER 3100 MacCorkle Avenue, SE, Suite 408 Charleston, WV 25304 (304) 388-5120 Office (304) 388-5125 Fax

Please complete each section of this form so that we may serve you better. Do not leave any sections blank.

Name ______Date of Birth ______SS # ______First Middle Last Name

Age ______Primary Care Physician ______Referring MD ______Other MD______

Reason for today’s visit ______

Are you currently experiencing any problems: (Please Check)  yes  no Fever, chills, weight loss  yes  no Psychiatric condition  yes  no Eyes  yes  no Blood and/or Lymphatic problems  yes  no Ears, Nose, Mouth, Throat  yes  no Seizures/Epilepsy/Strokes  yes  no Heart or Blood vessel problem  yes  no Skin and/or Breast Lesions or rashes  yes  no Breathing problems/Asthm a  yes  no Thyroid Disease/ gland problems/Diabetes  yes  no Stomach or intestinal  yes  no Kidney/Bladder Disease/Infection  yes  no Allergic/Immunologic problems  yes  no Muscle/Bone problems  yes  no HIV  yes  no Hepatitis  yes  no TB  yes  no SexuallyTransmitted Diseases

Other Past Medical Problems Not Listed Above______

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Medication Allergies and Reactions ______

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Latex Allergies  Yes  No

Current Medication and Dosage that you take including over the counter medications ______

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Height ______Weight ______I consider my health as  GOOD  FAIR  POOR Do you use caffeine?  Yes  No Amount ______

Do you smoke?  YES  NO Amount______Chew  Yes  No Amount ______Do you drink alcohol?  YES  NO Amount_____ Did you smoke in the past and quit?  YES  NO How many years did you smoke? ______Previous Surgery Type Date Name of Surgeon

Are you pregnant?  Yes  No  Maybe Do you have an Advance Directive/Living Will?  YES  NO Family history (please check) Cancer  Yes  No (Who) ______High Blood Pressure  yes  no (Who)______Diabetes  Yes  No (Who) ______Stroke  Yes  No (Who) ______Heart  Yes  No (Who) ______Thyroid Disease  Yes  NO (Who) ______TB  yes  no (Who) ______Liver Disease  Yes  No (Who)______Psychiatric Care  yes  no (Who)______Melanoma  yes  no (Who)______

 Other Chronic Disease ______Who has ______

Signature of patient/Legal Guardian/Responsible Party ______

Date ______Witness ______

Physician’s Signature ______Date ______Time ______