General Surgery Patient Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Medical Record #: __________ Date: _________________

Chief Complaint

Reason for visit: ________________________________________

Surgical History

Previous Surgeries

1. Operation: _________________ Date: _________
2. Operation: _________________ Date: _________
3. Operation: _________________ Date: _________

Surgical Complications

Have you ever had problems with anesthesia? □ Yes □ No If yes, describe: _______________________________________

Medical History

Current Medical Conditions

• □ Hypertension
• □ Diabetes
• □ Heart Disease
• □ Lung Disease
• □ Bleeding Disorders
• □ Other: __________

Current Medications

Family History

Please indicate any family history of:

• □ Cancer (Type: __________)
• □ Bleeding Problems
• □ Anesthesia Complications
• □ Heart Disease

Social History

• Tobacco Use: □ Never □ Former □ Current
• Alcohol Use: □ Never □ Occasional □ Regular
• Occupation: _________________

Review of Systems

Please check any current symptoms:

General

• □ Fever
• □ Weight Loss
• □ Fatigue

Cardiovascular

• □ Chest Pain
• □ Irregular Heartbeat
• □ Swelling in Legs

Respiratory

• □ Shortness of Breath
• □ Chronic Cough
• □ Wheezing

Certification

I certify that the information provided is accurate and complete:

Signature: _________________ Date: _________