PAST MEDICAL AND SOCIAL HISTORY

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PLEASE CHECK THE BOXES WHERE APPROPRIATE TO YOUR MEDICAL CONDITIONSE NONE FeportedE AnemiaE AnginaE A*hritis , osteoE Arthritis, FlheumatoidE Asthmatt btpotar utsoroerll Bleeorng uisor0erlt utooo translustonE Blood Disorder , OtherI cancerE Cardiac Arrhythm jarl Cognative lmpairmentsJ DepressionE Diabetes, lnsulin DependentE Diabetes, Non Insulin DependentE Ear Disease, OtherE Ear lnfectionsE Ear TubesE Eating DisorderE Emphysema/COPD

fl Endocrine Disorder, OtherI Eye DiseaseX FibromyalgiaIl Gastroesophageal Flef lux Diseasefl claucomaE GoiterE HrvE Head TraumaE Hearing AidsE Hearing LossE Heart AttackE Heart Disease, OtherE Heart Valve ProblemE HepatitisE High Blood PressureE High CholesterolE Hyperthyroidism (Over Active)fl Hypothyroidism (Under Active)I Kidney Disease, otherI Kidney Disease, On DialysisE Kidney Stone

E Liver DiseaseE Lung Disease, OtherE LupusE Meniere's Disease/Labyrinthitisfl Migraine Headachesfl N/litral Valve ProlapseI v]ultiple scterosisI Ny'usculoskeletal Disorder, other,1 Nasal; Fracturef, Neurological Disease, Othertr Noise ExposureE osteoporosisE Parathyroid Problem (High Calc'um)E Parkinson's DiseaseE Seizure DisorderE Sexually Transmitted DiseaseE Sleep ApneaE strokefl Substance AbuseD Thyroid DiseaseD Thyroid NoduleLJ I UmOrS. Uenrgn

fi Other Medical Conditions;

fl Cancer Location:Date Diagnosed: E Treatmenl I Radiation E Surgery I Chemotherapy

Additional Cancer Related Information:

CHILDHOOD MEDICAL HISTORYI NoNE Reported E chickenpoxEADHD E childhood Hearing LossE Apgar Score Less than 6 E Developmental DelaysE Asthma E DiabetesE Birth Nilarks E Ear InfectionE Birth Weight Less than 3.3 E Head InjuryE Pounds I MeaslesE Born Premature I N4eningitisE cerebral Palsy I N.4ononucleosis

E Other Childhood lvledicai History Iniormation :

E trilumpsE PneumoniaE Recurrent CroupE Required lntubation at BirthrJ Hneumaltc FeverE RubettaE Speech DelayE Strep Throat

PREVIOUS HISTORY OFf, NONE ReportedE cardiac ArrhythmiaE Cardiovascular Collapse

PROBLEMS WITH ANESTHESIAn Diificult lntubationE Hyperthermia, MalignantE Nausea

S Took a long time lo wake upI Vocal Cord InjuryU Vomiting

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PAST MEDICAL AND SOCIAL HISTORY continuedMEDICATIONSAllergies to Medications? D yes D t'tolf "Yes". olease list & Describe Reaction

Currently Taking Medication: E Yes E No lf "Yes" , Please list:1 A

2 5

o

PREVIOUS SURGERIESE nOrue Reportedf AngioplastyU Carotid EndarterectomvE other

E Coronary Artery Bypass Graft (CABG)iJ Coronary Artery StentingE Gastric Bypass

E Cardiac Defibri l latorf Pacemakerf Tonsil lectomy

SOCIAL HISTORYSMOKING HISTORY

E nONf reoortedE Current Every Day Smokerf Current Some Day SmokerE Former Smokerf, Smoke 1 1l2ppdf Smoke 1 ppdf Smoke 112 ppdf Smoke 2 ppd

ALCOHOL HISTORYE None reportedf Current Alcohol Use OccasionallvI Current Alcohol Use Rarelvf Current Excessive Alcohol Useil Former Alcohol Abusefl Former Alcohol Use OccasionallyE Never Used Alcohol

DRUG HISTORYE Denies Drug UseU Current Drug UserI,J Current l l legal lV Drug User,-l Current l l legal Inhalation Drug Usefl Current Prescription Drug AddictionE Former l l legal lV Drug UserE Former l l legal Inhalation Drug UsetJ Former Prescription Drug Addiction

EXERCISE HISTORY: E Currently None E Currently Darly f, Currently Several Times a Week E Currently Sporadic

OCCUPATION:

FAMILYHISTORY M = Mother F = Father S = Sister B=Brother O=Other

Hearingloss D tr t iJ XHeaftDisease f tr E rJ IHypertension trEt l 3trHyperthyroidism(overActive) E n I tr trHypothyroidism(underActive) tr t X tr f,KidneyDisease tr tr I tr IKidneyStones f, tr tr f IMental lllness tr tr t I E

MF S B ONONE reported nAlcoholism tAnesthesiaComplication tRlcedinn lliqnrdcr fCancer fDiabetes f,Emphysema/Asthma/COPD IHeadache, Chronic t

REVIEW OF SYSTEMSlN THE PAST MONTH. HAVE YOU HAD ANY PROBLEMS RELATED TO THE FOLLOWING I

IfntretfE

fDtr t ]E3trnf t r t rDftr t r t rt r t r t r t r8tr t r t rt r [ t r ft r t r f I

Noncontributory DParathyroid Disease (high calclum) trProblems with Anesthesia DSeizure Disorder EThyroid Cancer trThyroid Disease trTuberculosis DUnknown f

MF S B OEtfTEtrt rEtt rEI]t r f , t rt r f , t rTTft ]EE

CONSTITUTIONALSYSTEMSf Chi l lsf Fatiguef Feverf, Daytime Sleepinessf Sweatsf Weight Gainf Weight Loss

EARSf Hearing LossI Ear Painf Ringing

NOSEf Bloody NoseI ObsiructionE Post Nasal DripI Sense of Smel l ,f, Decreasedf Sinus Pressuref Sneezing

CARDIACf Chest Painf Tachycardia

(Rapid Heartbeat)

f Shortness of Breath f, not FlashesI Snoring f Intolerance to ColoI Wheezing

GASTROINTESTINALfl Constipationf DiarrheaI Heartburnf Indigest ion

MUSCULARf Arthrit isf Muscle Aches

RESPIRATORYf Cough

ENDOCRINEf Fatigue

HEMATOLOGICf Bleeding, easyI Bruising, easy

LYMPHATICf Enlarged Lymph Nodesf Neck Mass

ALLERGY/IMMUNOLOGrcf Allergies, Seasonalf Sneezingf Tongue Swelling

NEUROLOGICALf Dizzinessf Headachef Tremor

THROATf Altered Tastefl Halitosis (Bad Breath)f Hemoptysis (Blood)f Swallowing Diff icultyf Throat, Soref Voice Change

EYESf Diptopia (Double Vision)f lrritationf itctring

SKINf Skin DrynessE MRSA

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