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The purpose of this consult is to discuss
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Referred by:
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Employer:
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Occupation:
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Marital Status
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Responsible party? Name/Relation/Phone#
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Do you have any medical conditions?
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Cardiovascular
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If yes, check all that apply.
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Hematologic/Metabolic
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If yes, check all that apply.
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Eye, Ear, Nose
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If yes, check all that apply.
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Musculosketal
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If yes, check all that apply.
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Gastrointestinal
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If yes, check all that apply.
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Pulmonary
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If yes, check all that apply.
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Neurologic
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If yes, check all that apply.
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Psychiatric
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If yes, check all that apply.
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Medical problems that have not been covered
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Patient Height/Weight
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Do you smoke cigarettes?
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Frequency
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Do you use recreational drugs?
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Frequency
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Do you drink alcoholic beverages?
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Frequency
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Any issues associated with Anesthesia?
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History of Pneumothorax?
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Have you ever been diagnosed with sleep apnea?
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If yes, who is the diagnosing physician?
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Name of your primary physician:
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City & Phone number of primary physician
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Are you currently under the care of a physician?
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If yes, for what medical condition
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Have you ever had surgery?
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Date and Type of Surgery
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Surgeon:
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Date and Type of Surgery
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Surgeon:
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Date and Type of Surgery
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Surgeon:
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Date and Type of Surgery
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Surgeon:
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Date and Type of Surgery
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Surgeon:
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Have you ever been hospitalized?
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Hospitalization(other than surgery listed above)
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Physician/Date
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Hospitalization(other than surgery listed above)
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Physician/Date
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Hospitalization(other than surgery listed above)
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Physician/Date
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Hospitalization(other than surgery listed above)
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Physician/Date
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Medications
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Do you take any medications?
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Do you take Aspirin?
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Frequency
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Do you take Bleomycin?
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Do you take Cisplatin?
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Do you take Disulfiram?
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Do you take Doxorubicin?
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Do you take Sulfamylon?
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Name Medication & Strength/Dose
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Condition treated:
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Name Medication & Strength/Dose
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Condition treated:
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Name Medication & Strength/Dose
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Condition treated:
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Name Medication & Strength/Dose
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Condition treated:
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Name Medication & Strength/Dose
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Condition treated:
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Name Medication & Strength/Dose
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Condition treated:
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Addition Medications:
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Birth Control:
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Do you take any diet medication?
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Diet Medications:
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Frequency
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Do take any vitamins?
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Vitamins/Dose
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Frequency
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Vitamins/Dose
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Frequency
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Vitamins/Dose
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Frequency
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Additional Vitamins:
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Herbal Supplement?
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Do you have any allergies to medications?
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Please list reaction or sensitivity to each medication allergy.
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Allergies
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Allergies
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Allergies
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Allergies
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Allergies
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Allergies
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Are you allergic to latex?
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Are you allergic to adhesives?
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Family medical history,check all that apply.
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Other
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