Vascular Surgery Patient Health Questionnaire PLEASE COMPLETE ALL PAGES AND BRING FORM WITH YOU TO CLINIC
Name: ____________________________________
Date of Visit: ______________________________
Date of Birth: ______________________________
UM Registration #: _________________________
Home Phone: (_____) _______________________
Cell Phone: (_____) ________________________
Work Phone: (_____) ________________________
Email Address: _____________________________
Place of Work: _____________________________
Can we send you an email?
Emergency Contact: _________________________
Emergency Phone: (_____) ____________________
Contact Relationship: ________________________
Does this person live with you?
REFERRING PHYSICIAN:
Primary Care
Yes Yes
No No
Specialist / What Type: ______________
Name of Referring Physician: _____________________________________________________________ Address: ______________________________________________________________________________ City: _____________________________________
State: ______________ Zip: __________________
Office Phone: (_____) _______________________
Office Fax: (_____) _______________________
IF REFERRING PHYSICIAN IS NOT PRIMARY CARE, PLEASE PROVIDE INFORMATION Name of Primary Care Physician: __________________________________________________________ Address: ______________________________________________________________________________ City: _____________________________________
State: ______________ Zip: __________________
Office Phone: (_____) _______________________
Office Fax: (_____) _______________________
REASON FOR VISIT: ___________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ PREVIOUS SURGERIES DATE
TYPE OF SURGERY
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
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______________________________________________________________
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______________________________________________________________
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______________________________________________________________
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______________________________________________________________
Updated on 5/11/2010
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PREVIOUS HOSPITALIZATIONS DATE
REASON FOR HOSPITALIZATION
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
_______________
______________________________________________________________
ARE YOU CURRENTLY ON DIALYSIS?
Yes
No
(If yes, please complete information below)
Name of Dialysis Center: _______________________________ Dialysis Physician: _____________________ Address: __________________________________________________________________________________ City: _____________________________________
State: ______________ Zip: ______________________
Office Phone: (_____) _______________________
Office Fax: (_____) ___________________________
PREVIOUS STRESS TEST?
Yes
No
(If yes, in the past year?
Yes
No)
Name of Cardiologist: ______________________________________________________________________ Address: _________________________________________________________________________________ City: _____________________________________
State: ______________ Zip: _____________________
Office Phone: (_____) _______________________
Office Fax: (_____) __________________________
**PLEASE BRING A COPY OF YOUR LAST STRESS TEST TO YOUR APPOINTMENT** MEDICAL HISTORY (Check/fill in all that apply) Seasonal Allergies
Food Allergies: ______________
Abdominal Aneurysm (stomach)
Thoracic Aneurysm (chest)
Carotid Aneurysm (neck)
Renal Aneurysm (kidney)
Popliteal Aneurysm (knee)
Other Aneurysm: _____________
Arthritis
Asthma
Benign Prostatic Hypertrophy
Bleeding Disorder
Cancer: ____________________
Affected area: _________________
Radiation
Chemotherapy
Carotid Stenosis (narrowing)
Cataracts
Head Circulation Problems
Neck Circulation Problems
Arms Circulation Problems
Hand Circulation Problems
Legs Circulation Problems
Peripheral Angioplasty (non-heart)
Peripheral Stent (non-heart)
Coronary Artery Bypass
Coronary Artery Angioplasty/Stent
Coronary Artery Disease
Heart Attack
Heart Failure
Heart Valve Disease
Deviated Septum
Updated on 5/11/2010
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Diabetes Mellitus
Age of Diabetes Diagnosis _____
Diabetes Diet Controlled
Insulin Dependent
Oral Diabetes Medication
Emphysema
Oxygen Dependent
DVT (Vein blood clot)
DVT Location:_______________
Clot in Lungs
Gallstones
Gastroesophageal Reflux (GERD)
Glaucoma
Gout
Gynecological Problems
Hearing Problems/Aids
Hepatitis, Type: ______________
High Cholesterol
High Blood Pressure
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Irritable Bowel Syndrome
Osteoporosis
Kidney Problems
Peritoneal Dialysis
Hemodialysis
BUN (if known): ____________
Creatinine (if known): _________
Lupus
Depression
Anxiety
Other Mental Disorder: _________
Pacemaker/Defibrillator
Type?:_______________________
When Placed?:__________________
Peptic Ulcer Disease
Bleeding Ulcer
Raynaud’s Disease
Seizures/Epilepsy
Sleep Apnea
CPAP/BIPAP ________ Setting
Stroke
Transient Ischemic Attack (TIA)
Varicose Veins
Other: ____________________
Other: ____________________
Other: ____________________
___________ Liters
SOCIAL HISTORY Gender:
Male
Female
Transgendered ( MTF
FTM)
Married:
Yes
Divorced
Widowed
Children:
No
Yes
How many: _______________________________
Other ____________________
Occupation: ______________________________________ Retired
If yes, when? __________
Religion: _______________________________________________________________________________ Do your religious beliefs affect your medical decisions/treatment options?
Yes
No
If yes, please specify: _____________________________________________________________________ Home environment:
Apartment
House
Other
Number of people living in your home: ____________ Number of stairs in your home: ________________ Does anyone in your home have a significant health problem?
Yes
No
If yes, please specify: _____________________________________________________________________ Do you have family members or friends that are able to help you out?
Updated on 5/11/2010
Yes
No
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Do you have any of the following? If you do, please bring a copy with you for our records Advance Directive
Living Will
Durable Power of Attorney
If no, would like us to provide you with information? Do you have a regular exercise program?
Yes
Yes
If yes, # of days per week: ______________
No
No # of minutes per session: __________________________
Type: __________________________________________________________________________________ Barriers to exercise? No
Yes if yes, please explain: _________________________________
Smoking Status:
Quit; when: _____________ How long before quitting: __________
Never
Current; packs per day: _______________ How many years: ________________ If current or past; what type?
Cigarettes
Cigars
Pipe
Yes
No
Do you use recreational or intravenous drugs?
Chewing Tobacco
If yes, what type? ____________________________ How many years? _____________________________ Do you drink alcohol?
No
Yes
If yes, what type?
Wine
Beer
Liquor
If yes, how many? _________________ drinks/day (1 = 5oz wine = 12oz beer = 1.5oz liquor) FAMILY HISTORY Please check any condition below that any blood relative has experienced and note relationship (e.g. Father, sister, etc.)
Alcoholism
Allergies
Amputation
Aneurysm (location: __________)
Asthma
Blood Clots in Legs
Blood Clots in Lungs
Blood Clotting Problems
Blood Thinning Medication
Cancer (Type: _______________)
Cholesterol Problem
Chron's Disease
Circulation Problems (Leg/Arm)
Cirrhosis
Colitis
Diabetes
Easy Bleeding/Bruising
Emphysema
Heart Attack (age: ____________)
Heart Disease
High Blood Pressure
Irritable Bowel Disease
Lupus
Rheumatoid Arthritis
Seizure or Epilepsy
Stroke
Thyroid Trouble (Goiter)
Tuberculosis
Varicose Veins
Other: ________________________
MEDICATIONS/ALLERGIES Are you allergic or have you had a “bad reaction” to? Latex:
No
Contrast (IV Dye):
Updated on 5/11/2010
Yes No
If yes, what type of reaction: __________________________________ Yes
If yes, what type of reaction: ___________________________
Page 4 of 8
Have you had a reaction to other medications or substances?
No
Yes
If yes, specify below
________________________________________________________________________________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________ What medications do you presently take? Medication Name
Dosage (Amount)
Example: Lipitor
10mg
Frequency (How Often) 2x per day
Do you take any non-prescription medicines, herbal remedies, or tonics? (e.g. laxatives, diet pills, vitamins, antacids, or cold remedies)
No Yes
If yes, specify below
Name of Medicine, Remedy, Tonic, etc. Example: Multivitamin
Updated on 5/11/2010
Dosage (Amount) 1 pill
Frequency (How Often) 1x per day
Page 5 of 8
REVIEW OF SYSTEMS (Check/fill in all that apply) Cardiovascular Chest Pain
Anemia
Ankle Swelling
With Exercise
Blood Clots
Fainting
At Rest
High Blood Pressure
Irregular Heart Beat
Endocrine Intolerant to Heat or Cold
Hair Loss
Sweating (Night Sweats)
Eyes, Ears, Nose & Throat Blindness in one eye
Blurry Vision
Change in Vision
Deafness
Hoarseness
Lack of Vision in Visual Field
Loose and/or Painful Teeth
Nosebleeds
Post Nasal Drip
Ringing in Ears
Shade Going Over Eye
Sores in Mouth
Gastrointestinal Abdominal Pain Rate on a scale of 0 to 10 (0 = no pain, 10 = extreme pain) _______________ Abdominal Bloating
Change in Appetite
Constipation
Diarrhea
Difficulty Swallowing
Foul-smelling, Dark Stool
Heartburn
Jaundice
Nausea
Painful Swallowing
Vomiting
Vomiting Blood
Weight Gain
Weight Loss
If Over Age 50: Date of last Endoscope: ____________ Sigmoidoscopy: ______________ Colonoscopy: ________________ Gynecological (Females Only) Date of last pap smear: ___________________
Date of last mammogram: ___________________
Date of last menses: _____________________
Type of contraception: ______________________
Menses:
Regular
Irregular
Hormone Therapy:
Current
Past Hematological
Blood Clotting
If yes, specify
Artery
Easy Bruising
Prolonged Bleeding
Vein
Musculoskeletal/Skin Back Pain Updated on 5/11/2010
Cramping with Exercise
Finger Sores Page 6 of 8
General Weakness
Gout
Heaviness/Achiness in Legs
Joint Pain/Stiffness
Leg Fatigue w/ Prolonged Standing Neck Pain
Numbness and/or Tingling
Skin Color Changes
Leg Pain at Rest
Upper Extremity Discomfort with Activities
Sores on Legs and/or Feet
Lower Extremity Discomfort with Activities How far can you walk? __________ feet, __________ yards, __________ blocks Location of your leg pain?
Buttock
Thigh
Neurological
Calf
Foot
(Dominant Side Right
Left)
Difficulty Moving a Side or Limb
If yes, specify:
Right
Left
Both
Numbness of a Side or Limb
If yes, specify:
Right
Left
Both
Dizziness
Head Trauma
Headache
Loss of Consciousness
Memory Loss
Paralysis
Seizures
Shakiness
Slurred Speech
Tremors
Weakness Respiratory
Cough Shortness of Breath
Coughing up Blood If yes, specify:
At Rest
Wheezing
With Exertion
Snoring
Number of pillows you sleep on? ________________ Are you able to climb up a flight of stairs without shortness of breath? Do you awaken short of breath?
Yes
No
Do you sleep in a chair instead of a bed?
Yes
No
Yes
No
Psychological Change in Sleeping Patterns
Depression
Difficulty Concentrating
Feeling of Hopelessness
Feeling of Helplessness
Guilty Feelings
Hearing Voices
Loss of Sexual Desire
Nervousness
Social Withdrawl
Tension
Mental Abuse
If yes, specify:
Past
Present
Physical Abuse
If yes, specify:
Past
Present
Thoughts of Suicide* * If you are at immediate risk to harm yourself or others, please dial 911 or go to the nearest Emergency Room. Urological Blood in Urine
Flank Pain
Frequent Urination
Kidney Stones
Incontinence
Pain with Urination
Updated on 5/11/2010
Page 7 of 8
How many times do you urinate at night, if any? _____________________________ [Men Only]: Date of last prostate exam: _____________________________________
Patient or Guardian Signature: ___________________________________ Date: ___________________ Physician Signature: ____________________________________________ Date: ____________________
Updated on 5/11/2010
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