Medical History Form For Plastic Surgery and Dermatology PatientsSummit Medical History Form Thank you for taking time today to fill out your medical history forms. This helps to give your provider a detailed picture of your general overall health before your appointment.Step 1 of 333%Contact Information and Past Medical HistoryName* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Email Preferred Language Ethnicity and RaceAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther RaceDecline to SpeicifyPast Medical History: (Please check all that apply):* None Adrenal insufficiency Anemia/thalassemia Anxiety Arthritis Asthma Autoimmune disease Atrial fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes Easy bruising End Stage Renal Disease GERD Head Trauma Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Leukemia Lung Cancer/disease Leukemia Lupus Lymphoma Malignant hypertension Mental health hospitalization Neuromuscular disorder Paralysis Pneumothorax Prostate Cancer Pulmonary embolism Radiation Treatment Reflux Renal disorder Rheumatoid arthritis Seizures Severe reaction to anesthesia Sleep apnea Snoring Stroke Trauma Valvular heart disease Vision lossOther Past Medical History Not ListedPast Surgical History* None Angioplasty (PTCA) Appendix removed (Appendectomy) Bladder removed (Cystectomy) Brain surgery (cancer/trauma) Breast: Breast Biopsy (Both, Left or Right) Breast: Lumpectomy (Both, Left or Right) Breast: Mastectomy (Both, Left or Right) C-section Colectomy Colostomy Gallbladder removed (Cholecystectomy) Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Surgery Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA Joint replacement: Hip (Both, Left or Right) Joint replacement: Knee (Both, Left or Right) Joint replacement within the last 2 years Joint Replacement: Other Kidney: Biopsy Kidney: Stone Removal Kidney: Transplant Kidney removed (Nephrectomy): Left or Right Liver removed: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries (Oophorectomy): due to Endometriosis, Ovarian Cancer or Ovarian Cyst Ovaries: Tubal Ligation Ovaries: Removed Pancreas removed (Pancreatectomy) Prostate Biopsy Prostate removed (Prostatectomy): due to Prostate Cancer Prostate resection: TURP Rectum Resection Spleen removed (Splenectomy) Stomach removed Testicles removed (Orchiectomy): Both, Left, Right Uterus removed (Hysterectomy): due to fibroids, Uterine or cervical cancerOther Past Surgical History Not ListedSkin Disease History: (Please check all that apply)* None Acne Actinic Keratoses Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking/Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Skin CancerOther Skin Disease History Not ListedWhat is/are your preferred method(s) for sun protection? Nothing < 30 SPF Sunscreen >30 SPF Sunscreen Protective ClothingDo you tan in a tanning bed?YesNoDo you have a family history of Melanoma?*YesNoIf yes to melanoma, which relatives Mother Father Sister Brother Grandmother GrandfatherPlastic Surgery History* None Abdominoplasty Blepharoplasty Brachioplasty Breast augmentation Breast lift (mastopexy) Breast reconstruction Breast reduction Brow lift Cheek augmentation Chin Implant Eyelid surgery Facelift Facial fracture repair Frontal sinus fracture Fraxel Hand Surgery Liposuction Lower body lift Mini facelift/S-Lift Male Breast Reduction Mandible fracture Maxillary fracture Liposuction Necklift Orbital floor fracture Otoplasty Post Bariatirc Surgery Rhinoplasty Septorhinoplasty Thigh lift Tummy tuck Upper body lift Wrist fracture repair Zygoma fractureOther plastic surgery not listed.Do you have a family history of breast cancer?*YesNoHave you or any family members ever had any problems with anesthesia in the past?*YesNoDo you have a family history of malignant hyperthermia or severe reactions to anesthesia?*YesNoIf yes, which relative?MotherFatherSisterBrotherGrandmotherGrandfatherMedications and Medical AlertsHerbal Medication or Supplements (Please check all that apply)* None Anabolic steroids Androstenedione Black cohosh Cat's claw Chondroitin Cranberry Echinacea Ephedra Evening primrose Feverfew Fish oil Flaxseed oil Garlic Gingko biloba Ginseng Glucosamine Goldenseal Green tea Hawthorn HCG Horse chestnut Human growth hormone Kava Licorice root Mistletoe Peppermint Phentermine Red Clover Saw palmetto St. John's Wort Valerian Vitamin A Vitamin B Vitamin C Vitamin D Vitamin EMedications: (Please list all medications here. To upload a list of medications see below)If you are not currently taking any medications, please write "no medications". Upload Medications List Here Drop files here or Allergy List File UploadDrug Allergies: (Please list all known allergies and reactions. If none, please write none in the first collumn.)Allergy #1Allergy #2Allergy #3Allergy #4Allergy #5Allergy #6 Smoking Status*Current Every Day SmokerCurrent Someday SmokerFormer SmokerNever SmokedAlcohol Use:*None< 1 drink per day1-2 drinks per day3 or more drinks per dayMedical Alerts: (Please check all that apply)* None Currently taking blood thinners Allergic to adhesive Allergic to latex Allergy to topical antibiotic ointments Allergy to lidocaine Artificial joint replacement within 2 years Artificial heart valve Cardiac Stents Deep vein thrombosis/pulmonary embolism Pacemaker or defibrillator Have a history of DVT/PE Have cardiac stent(s) History of MRSA Currently trying to get pregnant or pregnant MRSA Pacemaker or defibrillator Rapid heartbeat with epinephrine Thyroid problemsOther Medical Alerts Not ListedReview of SystemsAre you currently experiencing any of the following? Please selection yes or no.Are you generally in good health?*YesNoDo you have problems with bleeding?*YesNoDo you have problems with healing?*YesNoDo you have problems with scarring?*YesNoDo you currently have a rash?*YesNoDo you have any new skin lesions?*YesNoDo you have any changing lesions?*YesNoAre you pregnant or currently trying to get pregnant?*YesNoHave you previously had a flu vaccine?*YesNoDate of flu vaccine: Date Format: MM slash DD slash YYYY Have you previously had a pneumonia vaccine?*YesNoDo you have a living will?YesNoPower of Attorney/Advanced DirectiveDo you have a Medical Power of Attorney (for yourself) or an Advanced Directive prepared? If so, please indicate who.Have you been admitted to the hospital in the past 12 months?*YesNoIf you have been admitted to the hospital, please indicate why.To your knowledge, do you have a history of a difficult airway during previous surgeries?*YesNoHeight*Weight*Thank You!Thanks again for your time and effort to get the most up-to-date information to your provider. It is much appreciated. Please feel free to add any additional information, that you feel is important to your health record, in the box below.EmailThis field is for validation purposes and should be left unchanged.
