Pre-Surgical Medical History

Patient’s Name

Health at Present

If you have a history of any of the following conditions, please check the appropriate box(es):

Other

Last Medical Exam

Medications

Allergies

Aspirin

Codeine

Iodine

PCN

Tape

Other

Have you had any serious illnesses?

If so, which?

Have you had any previous surgeries?

If so, which?

Have you had any injury to your feet or legs?

If so, explain

Do you smoke?

Do you drink alcohol?

Do you drink coffee?

Any chance of pregnancy?

Do you take birth control pills?

Head, Ears, Eyes, Nose, Throat

Yes No

Bladder or Urinary

Yes No

Stomach or Intestines

Yes No

Heart or Lungs

Yes No

Liver of Kidney

Yes No

Musculosekletal

Yes No

Nature of Complaint

Onset

Location

Duration

Self Treatments