SOUTHERN NEVADA SURGICAL SPECIALISTS

NEW PATIENT AND PREOPERATIVE QUESTIONNAIRE

NAME: _________________________________________ AGE: __________

ILLNESSES:

Do you have or have you had?

		YES			                YES

Rheumatic Fever?____	    High Blood Pressure?	____
Diabetes?	____	    Heart Attacks?	        ____
Strokes?	____	    Heart Problems?	        ____
Lung Disease?	____	    Ulcers?	                ____
Asthma?	        ____	    Seizures?	                ____
Cancer?	        ____	    Other problems?	        ____
  
MEDICATIONS:
			Dosage	Frequency

1.	
2.	
3.	
4.

ALLERGIES TO MEDICATIONS:		Type of Reaction

1.
2.
3.

HOSPITALIZATIONS, OPERATIONS, MAJOR INJURIES:	Date

1.
2.
3.
4.

HABITS:

Do you smoke?	How Much?	How long?
Did you ever smoke?	When did you quit?
Heavy drinking in the past?
Drug use other than prescription? 




FAMILY MEDICAL HISTORY:

Do these illnesses run in your family?

		YES		YES
Diabetes?	____	High blood pressure?	____
Strokes?	____	Bleeding problems?	____
Heart attacks?	____	Sickle cell disease?	____

Father - Alive?	Illness?
		Cause of death?

Mother - Alive?	Illness?
		Cause of death?

Other causes of death in your family?

 SYSTEM REVIEW:

Do you now have or recently had the following problems?

			     YES	                        YES
Fevers?         	     ____	Chills?          	____
Sweats?	                     ____	Loss of weight?	        ____
Frequent/severe headaches?   ____	Changes in vision?	____
Changes in hearing?	     ____	Thyroid problems?	____
Frequent/severe nose bleed?  ____	Masses in the neck?	____
Hoarseness?	             ____	Chronic or daily cough? ____
Cough up blood?	             ____	Wheezing?	        ____
Breast lumps?	             ____	Discharge from nipples? ____
Chest pains?	 	     ____	Leg swelling?	        ____
Frequent nausea?	     ____	Frequent vomiting?	____
Vomited blood?	             ____	Abdominal pain?	        ____
Jaundice (yellow eyes/skin)  ____	Diarrhea?	        ____
Constipation?	             ____	Blood in stool?	        ____
Black stool?	             ____	White stools?	        ____
Blood in urine?	             ____       Smelly/cloudy urine?	____
Frequent small voids?	     ____
  


				                        YES
Frequent or severe ear, sinus or throat infections?	____
Do you cough up sputum daily?		                ____
 If so, how much? ________________________________
 What is the usual/most recent color? ____________
Ever have a skin test positive for Tuberculosis?	____
Does your heart race for no apparent reason?	        ____
Do you get out of breath with minimal exertion?	        ____
Do you wake up at night out of breath?	                ____
Do your legs cramp when you walk?		        ____
Pain or burning with urination?		                ____
Incontinence? (Loss of control)		                ____
Do you wake up at night to urinate?	                ____
 How many times each night? _______
How many times have you been pregnant? _______________
How many deliveries? _________________________________
How many miscarriages, abortions, or stillbirths? ____
Last menstrual period? _______________________________
Could you be pregnant? _______________________________
Excessive menses or irregular periods?	                ____
Menopause?			                        ____
 When? _______________________________________________
Do you have excessive bleeding or bruising?	        ____
Do you have any new lumps?			        ____
Do you have muscle or arthritis problems?	        ____
 Where? ______________________________________________
Do you have problems with fainting? 	                ____
Do you have problems with paralysis?	                ____
Do you have problems with loss of sensation or vision?	____

Thank you for your time and cooperation.  Your answers will make your care more complete. 



SIGNATURE _____________________________   DATE _________________